Cervical Cancer Awareness Month

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:13latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week it's a conversation about
00:21 --> 00:24cervical cancer with Doctor Mitchell Clark.
00:24 --> 00:25Doctor Clark is an assistant
00:25 --> 00:27professor of obstetrics, gynecology,
00:27 --> 00:28and Reproductive sciences at
00:28 --> 00:31the Yale School of Medicine,
00:31 --> 00:32where Doctor Chagpar is a
00:32 --> 00:34professor of surgical oncology.
00:36 --> 00:38Mitchell, maybe we can start off by
00:38 --> 00:39you telling us a little bit more
00:39 --> 00:41about yourself and what it is you do.
00:42 --> 00:43Absolutely. I'm
00:43 --> 00:45originally from Canada and I've been
00:45 --> 00:47here at Yale now for four years.
00:47 --> 00:50Prior to that at the University of Toronto,
00:50 --> 00:52where a lot of my research in
00:52 --> 00:53clinical activity was around
00:53 --> 00:55cervical cancer prevention,
00:55 --> 00:56awareness and obviously treatment of
00:56 --> 00:58those diagnosed with the disease.
00:58 --> 00:59Here at Yale
00:59 --> 01:00I'm a gynecologic oncologist
01:00 --> 01:03and part of a really robust
01:03 --> 01:05multidisciplinary team caring for
01:05 --> 01:07women with gynecologic cancers,
01:07 --> 01:08including cervical cancer.
01:09 --> 01:10So let's talk a little bit
01:10 --> 01:12more about cervical cancer.
01:12 --> 01:15Can you kind of paint us a broad
01:15 --> 01:18overview of what exactly is the disease?
01:18 --> 01:22How common is it?
01:22 --> 01:24What's the mortality from it?
01:24 --> 01:25I feel like a lot of us
01:25 --> 01:27talk about cervical cancer,
01:27 --> 01:29but we might not know the real details.
01:29 --> 01:30Absolutely.
01:30 --> 01:32We're very fortunate in this country
01:32 --> 01:34to have seen a dramatic decrease
01:34 --> 01:35in the rates of cervical cancer,
01:35 --> 01:38both in incidence and mortality.
01:38 --> 01:40And a lot of that has to do with
01:40 --> 01:41our robust screening program.
01:41 --> 01:44So many women are aware of the Pap smear,
01:44 --> 01:46something that they talk very often
01:46 --> 01:48with their gynecologists with and the
01:48 --> 01:50design around that is to prevent these
01:50 --> 01:52cancers and to detect them before
01:52 --> 01:54they even have a chance to develop.
01:54 --> 01:56And so women will meet
01:56 --> 01:57with their gynecologist,
01:57 --> 01:59have a Pap smear performed in a certain
01:59 --> 02:01interval of time and we try to detect these,
02:01 --> 02:02like I said,
02:02 --> 02:04before we even develop into a cancer.
02:04 --> 02:05Because of that,
02:05 --> 02:07we've seen a real decrease in
02:07 --> 02:08the rates of this disease.
02:08 --> 02:11However, we do still continue to
02:11 --> 02:13see patients present to the clinic,
02:13 --> 02:15often those who are not up to
02:15 --> 02:16date with their screening,
02:16 --> 02:17not up to date with the Pap smear,
02:17 --> 02:19who have unfortunately gone on
02:19 --> 02:21to develop a cervical cancer.
02:21 --> 02:22Often times though,
02:22 --> 02:23these are still diagnosed at
02:23 --> 02:25early stage because unlike many
02:25 --> 02:27other gynecologic cancers,
02:27 --> 02:29they often have a symptom and for
02:29 --> 02:30many women that can be bleeding
02:30 --> 02:32that is either irregular or out
02:32 --> 02:34of sync with their menses,
02:34 --> 02:35or bleeding in the post menopausal
02:35 --> 02:37period when women have ceased
02:37 --> 02:39having their menstrual period.
02:39 --> 02:40Because of this,
02:40 --> 02:42women present early where treatment
02:42 --> 02:44options continue to be very
02:44 --> 02:46favorable and for most women,
02:46 --> 02:47they will experience a good
02:47 --> 02:49outcome from their cancer care,
02:49 --> 02:52meaning that we're able to treat these
02:52 --> 02:53with curative, definitive intent.
02:53 --> 02:53However,
02:53 --> 02:56of course we will see and care
02:56 --> 02:58for women who present with more
02:58 --> 02:59advanced stage disease, and
03:02 --> 03:03there have never been as many
03:03 --> 03:05options now as there have been
03:05 --> 03:06in the past to care for those
03:06 --> 03:08women who unfortunately do come
03:08 --> 03:08with advanced disease.
03:10 --> 03:13So let's talk a little bit more about
03:13 --> 03:16how we can detect
03:16 --> 03:17cervical cancer early.
03:17 --> 03:19Can you talk a little bit more
03:19 --> 03:20about some of the guidelines
03:20 --> 03:21in terms of screening?
03:22 --> 03:24Absolutely. We're very fortunate that
03:24 --> 03:27this is one cancer where there is robust
03:27 --> 03:30data to support the use of screening.
03:30 --> 03:31Unlike other cancers like ovarian or
03:31 --> 03:33uterine where we don't have that data,
03:33 --> 03:36the Pap smear has really been effective
03:36 --> 03:38at detecting pre invasive disease or
03:38 --> 03:40changes in the cells of the cervix
03:40 --> 03:42before they develop into a cancer.
03:42 --> 03:45One of the most important discoveries has
03:45 --> 03:47been the association of the HPV virus in
03:47 --> 03:50its development and role in cervical cancer.
03:50 --> 03:53And so beginning all the way back in
03:53 --> 03:55adolescence now we know it's important to
03:55 --> 03:57offer vaccination to both boys and girls
03:57 --> 04:01ages 9 to 11 to help prevent HPV infection
04:01 --> 04:03and eliminate or dramatically reduce
04:03 --> 04:05that risk of developing down the road.
04:05 --> 04:07And so that data is very strong and
04:07 --> 04:09supported by a number of different
04:09 --> 04:11medical groups including Pediatrics.
04:11 --> 04:14For those women who then either
04:14 --> 04:16do or do not receive the vaccine,
04:16 --> 04:18the guidelines for screening with the Pap
04:18 --> 04:20smear are still the same at this time.
04:20 --> 04:22That may change down the road,
04:22 --> 04:25but for now we've come up with
04:25 --> 04:26a combination test where we screen
04:26 --> 04:29for both the HPV virus in the cells
04:29 --> 04:31and the presence of any microscopic
04:31 --> 04:33changes when our cytopathologists
04:33 --> 04:35look under the microscope and if
04:35 --> 04:37women have negative results from both
04:37 --> 04:38the HPV and the cells,
04:38 --> 04:40they're actually eligible to
04:40 --> 04:43be screened every five years.
04:43 --> 04:45And for a lot of patients and for
04:45 --> 04:48women that has been a big change from
04:48 --> 04:50what used to be an annual screening.
04:50 --> 04:53But we know that the association of a
04:53 --> 04:55negative HPV test with that screening
04:55 --> 04:58confers a strong degree of protection
04:58 --> 05:00over the course of the next five years.
05:00 --> 05:02And so women can feel reassured that
05:02 --> 05:04they have a very low likelihood of going
05:04 --> 05:06on to develop a pre cancer or cancer
05:06 --> 05:10of the cervix in the subsequent five years.
05:10 --> 05:12In terms of detection though,
05:12 --> 05:13and moving beyond screening,
05:13 --> 05:15patients need to present to the
05:15 --> 05:17gynecologist in the interim if they
05:17 --> 05:18feel that they're developing any of
05:18 --> 05:20those symptoms I talked about earlier.
05:22 --> 05:25And so can you talk a little
05:25 --> 05:26bit more about HPV vaccinations?
05:26 --> 05:30I mean, it seems like we talk a lot about
05:30 --> 05:33HPV in the association with cervical cancer,
05:33 --> 05:36but some people might still be
05:36 --> 05:38unaware about HPV vaccination,
05:38 --> 05:40who should get it, when they should get it.
05:40 --> 05:44And I understand that now the age guidelines
05:44 --> 05:46for HPV vaccination have expanded.
05:46 --> 05:48Can you talk a little bit more about that?
05:48 --> 05:51Absolutely. This is one of my favorite
05:51 --> 05:53topics because I think it's a unique
05:53 --> 05:56example of a vaccine that can be thought
05:56 --> 05:58of as a cancer prevention strategy.
05:58 --> 06:00I think when this first came out
06:01 --> 06:03in the early 2000s,
06:03 --> 06:05there was a lot of reluctance around
06:05 --> 06:07providing a vaccine that was associated
06:07 --> 06:09with a sexually transmitted infection.
06:09 --> 06:12However, we've seen just a dramatic
06:12 --> 06:15reduction in HPV associated cancers in
06:15 --> 06:18patients who use this vaccine early on.
06:18 --> 06:21And so the ideal time to offer
06:21 --> 06:23vaccination is really in that adolescent
06:23 --> 06:26period prior to first exposure to HPV.
06:26 --> 06:28And so we typically say between
06:28 --> 06:30the ages of 9 to 11 and I
06:30 --> 06:31would strongly encourage women,
06:32 --> 06:32men, parents,
06:32 --> 06:35grandparents, to have a very frank
06:35 --> 06:38conversation with the pediatricians about
06:38 --> 06:41ensuring that the HPV vaccine is included
06:41 --> 06:44in the vaccine series for girls and boys.
06:44 --> 06:46We know from some internal data in
06:46 --> 06:49the state of Connecticut that the
06:49 --> 06:51other vaccines recommended at 9 to 11
06:51 --> 06:53have an uptake rate over 90%.
06:53 --> 06:55But completion of the HPV vaccine
06:55 --> 06:57series in our state remains very
06:57 --> 06:59low at around 50 to 60%.
06:59 --> 07:01And there's really no reason
07:01 --> 07:02for this other than
07:03 --> 07:05some misinformation and reluctance
07:05 --> 07:07on providers and sometimes parents
07:07 --> 07:10in seeing the benefit to the vaccine.
07:10 --> 07:12Although I don't treat head and neck cancer,
07:12 --> 07:14we are seeing a really robust set
07:14 --> 07:16of studies coming out demonstrating
07:16 --> 07:18the association of HPV with cancers
07:18 --> 07:20of the head and neck.
07:20 --> 07:23And just another reason to reinforce
07:23 --> 07:25the parents and to children who are
07:25 --> 07:26taking the vaccine that we should
07:26 --> 07:28really look at this as a cancer
07:28 --> 07:30prevention strategy as opposed to
07:30 --> 07:32something that is associated with
07:32 --> 07:33an infection that's acquired through
07:33 --> 07:34sexual activity.
07:35 --> 07:40The reluctance on
07:40 --> 07:45people to take this vaccine I think is
07:45 --> 07:45really concerning.
07:46 --> 07:47And we've seen this not only
07:47 --> 07:49in our own state as you mentioned,
07:49 --> 07:53but even globally.
07:53 --> 07:55And I think
07:55 --> 07:58part of it is that
07:58 --> 08:00parents may say,
08:00 --> 08:03my child is not going to engage
08:03 --> 08:06in premarital sexual activity.
08:06 --> 08:09And so why should I vaccinate them
08:09 --> 08:13between the ages of nine and 11?
08:13 --> 08:15Can you talk a little
08:15 --> 08:17bit more about about that?
08:17 --> 08:18Absolutely,
08:18 --> 08:21it's parents and it's also providers.
08:21 --> 08:23We've done a lot of work internally
08:23 --> 08:25here in the state of Connecticut.
08:25 --> 08:27I work with the Department of Health on
08:27 --> 08:30this in educating both our Pediatrics
08:30 --> 08:32colleagues around ways to bring
08:32 --> 08:34up these discussions with parents.
08:34 --> 08:35There's a lot of
08:35 --> 08:37people who still feel uncomfortable for some
08:37 --> 08:40reason or another addressing a sexually
08:40 --> 08:43related topic in a patient of that age.
08:43 --> 08:46But the data really speaks for itself and I
08:46 --> 08:49think changing the narrative like I said,
08:49 --> 08:52to reinforcing this is to prevent a
08:52 --> 08:55cancer far down the road.
08:55 --> 08:58You know, we're not looking to provide
08:58 --> 09:01some sort of assurance to adolescents
09:01 --> 09:04that are having unprotected sex that it is safe
09:04 --> 09:05because they're vaccinated.
09:05 --> 09:07But really what we are looking
09:07 --> 09:08at is the long game here,
09:08 --> 09:10which is to prevent a cancer,
09:10 --> 09:12a multitude of cancers actually,
09:12 --> 09:14not just cervical cancer that
09:14 --> 09:17could be really life limiting.
09:17 --> 09:19And looking at the sort of long
09:19 --> 09:21term investment of this very safe
09:21 --> 09:23vaccine that has now been around
09:23 --> 09:24for over a decade.
09:29 --> 09:30If somebody is listening
09:30 --> 09:32to this and they think, OK,
09:32 --> 09:35I get it, but my child is now
09:35 --> 09:38beyond the age of 9 to 11 and maybe
09:38 --> 09:40they're in their late teens,
09:40 --> 09:42maybe even their early 20s,
09:42 --> 09:44can they still get the vaccine?
09:44 --> 09:47Absolutely. We've got a great
09:47 --> 09:49data set and clinical trials
09:49 --> 09:51showing effectiveness in what
09:51 --> 09:52we're calling the catch up cohort.
09:52 --> 09:54So those are a group of people
09:54 --> 09:56who did not have the opportunity
09:56 --> 09:58or maybe chose not to take the
09:58 --> 10:00vaccine in the earlier years
10:00 --> 10:01when it's initially recommended.
10:01 --> 10:04But we do still see statistically
10:04 --> 10:06significant benefits in a reduction
10:06 --> 10:08of HPV associated illnesses and
10:08 --> 10:10cancers in those people taking the
10:10 --> 10:12vaccine really up until their mid 20s.
10:12 --> 10:14There is some new data to say
10:14 --> 10:16that up until the sort of early
10:16 --> 10:1840s there may be benefit,
10:18 --> 10:20but it's quite individualized and the
10:20 --> 10:22recommendation is for for people to
10:22 --> 10:24discuss with their provider to see if
10:24 --> 10:25maybe they would be a good candidate.
10:25 --> 10:27But if we're looking at the
10:27 --> 10:29cost benefit here or
10:29 --> 10:30the risk benefit analysis,
10:30 --> 10:32this vaccine is very safe.
10:32 --> 10:34We don't see any major safety signals.
10:34 --> 10:37This has been around for a long time and
10:37 --> 10:39if you can confer any reduction in risk,
10:39 --> 10:42I think it's a really worthwhile
10:42 --> 10:44conversation for both these teens
10:44 --> 10:46and 20 year olds to
10:49 --> 10:50have with their doctors.
10:52 --> 10:54Is the vaccine covered by
10:54 --> 10:56most health plans?
10:56 --> 10:58Yes, most health plans do cover this
10:58 --> 11:01because it is recommended by both the
11:01 --> 11:04CDC and many major organizations
11:04 --> 11:07who make our sort of national
11:07 --> 11:09guidelines around vaccination.
11:09 --> 11:11And in the state of Connecticut for
11:11 --> 11:13certain age groups it's covered as well.
11:13 --> 11:15So these are things
11:15 --> 11:16that you should definitely bring
11:16 --> 11:17up with your pediatrician.
11:18 --> 11:20And now we actually have a number of
11:20 --> 11:22pharmacists and pharmacies that carry
11:22 --> 11:24the vaccine and do not necessarily
11:24 --> 11:27require the prescription of an MD.
11:27 --> 11:28And so I think you certainly
11:28 --> 11:30have that conversation with your
11:30 --> 11:32trusted healthcare provider.
11:32 --> 11:33And for those healthcare
11:33 --> 11:34providers out there listening,
11:34 --> 11:36I cannot reinforce enough the
11:36 --> 11:38importance of your strong
11:38 --> 11:40recommendation to parents and kids.
11:40 --> 11:42We know that's the number one reason,
11:42 --> 11:44or that is associated with vaccine
11:44 --> 11:46uptake, is recommendation because
11:46 --> 11:48you have that strong therapeutic
11:48 --> 11:49relationship with your patients and
11:50 --> 11:51their families and to either seek this
11:51 --> 11:53through the clinic that you see that
11:53 --> 11:55you get carrying or to see go to
11:55 --> 11:56local pharmacy who has it in stock.
11:57 --> 12:00Is the vaccine given in one shot
12:00 --> 12:03or is it multiple shots that you
12:03 --> 12:05require to get immunity?
12:05 --> 12:08Great question. So it is designed to be a
12:08 --> 12:10multi shot regimen depending on the
12:10 --> 12:13age whether it will be two or three.
12:13 --> 12:15Although we have seen some data
12:15 --> 12:17coming out of countries that are lower
12:17 --> 12:20middle income where access to a repeated
12:20 --> 12:22series is not reasonable or feasible
12:22 --> 12:25and there has been some very exciting
12:25 --> 12:26results showing strong immunogenicity
12:26 --> 12:29even if you just get one shot.
12:29 --> 12:32Obviously we recommend patients get all
12:32 --> 12:35two or all three depending on their age,
12:35 --> 12:37but at least just getting the one
12:37 --> 12:39seems to to confer some protection and
12:39 --> 12:41that is long lasting at least.
12:42 --> 12:44Can you clarify who gets two
12:44 --> 12:46shots and who gets three shots?
12:46 --> 12:47You mentioned that has
12:47 --> 12:49something to do with age.
12:49 --> 12:52So in the younger 9 to 11 population,
12:52 --> 12:55the 2 is fine. Those of us in the catch
12:55 --> 12:58up cohort who would be getting it in
12:58 --> 13:00the early 20s would be the three shot.
13:01 --> 13:04OK, so let's suppose you have a
13:04 --> 13:07child who has gotten vaccinated.
13:07 --> 13:09Do they still need Pap smears
13:09 --> 13:12and HPV tests and if so,
13:12 --> 13:13when should those start?
13:14 --> 13:15That's a great question.
13:15 --> 13:18For right now, we do not have any
13:18 --> 13:19different guidelines for people
13:19 --> 13:22who are vaccinated or unvaccinated.
13:22 --> 13:24And the Pap smears usually start
13:24 --> 13:26somewhere between 21 to 25.
13:26 --> 13:28And we defer the HPV testing to
13:28 --> 13:30around 30 just because we know
13:30 --> 13:32this virus is so prevalent in
13:32 --> 13:35the community and it takes many,
13:35 --> 13:37many years for those cell changes to happen.
13:37 --> 13:39So it can be a little complicated,
13:39 --> 13:41but we have tried to make it as
13:41 --> 13:43clear as possible for the
13:43 --> 13:45family docs and gyns in the community.
13:45 --> 13:46Perfect.
13:46 --> 13:48Well, we need to take a short
13:48 --> 13:49break for a medical minute.
13:49 --> 13:51Please stay tuned to learn more about
13:51 --> 13:53the care of patients with cervical
13:53 --> 13:55cancer in honor of Cervical Cancer
13:55 --> 13:56Awareness Month with my guest,
13:56 --> 13:57Doctor Mitchell Clark.
13:58 --> 14:00Funding for Yale Cancer Answers
14:00 --> 14:02comes from Smilow Cancer Hospital,
14:02 --> 14:04where the lung cancer Screening program
14:04 --> 14:07provides screening to those at risk
14:07 --> 14:09for lung cancer and individualized,
14:09 --> 14:11state-of-the-art evaluation of lung nodules.
14:11 --> 14:16To learn more visit smilocancerhospital.org.
14:16 --> 14:18Breast cancer is one of the
14:18 --> 14:20most common cancers in women.
14:20 --> 14:21In Connecticut alone,
14:21 --> 14:23approximately 3500 women will be
14:23 --> 14:26diagnosed with breast cancer this year.
14:26 --> 14:27But there is hope thanks
14:27 --> 14:28to earlier detection,
14:28 --> 14:29non invasive treatments,
14:29 --> 14:31and the development of novel therapies.
14:32 --> 14:33To fight breast cancer,
14:33 --> 14:36women should schedule a baseline mammogram
14:36 --> 14:38beginning at age 40 or earlier if they have
14:38 --> 14:41risk factors associated with the disease.
14:41 --> 14:42With screening,
14:42 --> 14:43early detection,
14:43 --> 14:44and a healthy lifestyle,
14:44 --> 14:46breast cancer can be defeated.
14:46 --> 14:48Clinical trials are currently
14:48 --> 14:50underway at federally designated
14:50 --> 14:51comprehensive cancer centers,
14:51 --> 14:53such as Yale Cancer Center
14:53 --> 14:55and Smilow Cancer Hospital,
14:55 --> 14:57to make innovative new
14:57 --> 14:59treatments available to patients.
14:59 --> 15:01Digital breast tomosynthesis or 3D
15:01 --> 15:04mammography is also transforming breast
15:04 --> 15:06cancer screening by significantly
15:06 --> 15:07reducing unnecessary procedures
15:07 --> 15:10while picking up more cancers.
15:10 --> 15:12More information is available
15:12 --> 15:13at yalecancercenter.org.
15:13 --> 15:17You're listening to Connecticut Public Radio.
15:17 --> 15:17Welcome
15:17 --> 15:19back to Yale Cancer Answers.
15:19 --> 15:20This is Doctor Anees Chagpar,
15:20 --> 15:22and I'm joined tonight by my guest,
15:22 --> 15:23Doctor Mitchell Clark.
15:23 --> 15:25We're discussing the care of
15:25 --> 15:26patients with cervical cancer.
15:26 --> 15:27Now before the break,
15:27 --> 15:30we talked a lot about screening and
15:30 --> 15:34prevention with HPV tests and Pap smears
15:34 --> 15:37and the very important HPV vaccine.
15:37 --> 15:39But Mitchell, now I want to pivot a
15:39 --> 15:42little bit into patients who
15:42 --> 15:45are found to have cervical cancer.
15:46 --> 15:49Can you talk a little bit more about
15:49 --> 15:51how cervical cancer is diagnosed
15:51 --> 15:54and how is that diagnosis made,
15:54 --> 15:58whether on a Pap smear or symptomatically?
15:59 --> 16:01In general, we tend to detect
16:01 --> 16:03these symptomatically because the
16:03 --> 16:05Pap smear is really designed to
16:05 --> 16:07detect precancerous changes where
16:07 --> 16:09an intervention can be undertaken
16:09 --> 16:11to prevent development into cancer.
16:11 --> 16:13And so patients will often have
16:13 --> 16:15some type of bleeding symptom or
16:15 --> 16:17some pelvic discomfort or pain.
16:17 --> 16:19But in general, there will be some
16:19 --> 16:21bleeding either between the periods
16:21 --> 16:22or in the postmenopausal period,
16:22 --> 16:24which prompts an evaluation
16:24 --> 16:26by the gynecologist.
16:26 --> 16:27When patients go to the office,
16:27 --> 16:29they can expect that their gynecologist
16:29 --> 16:32will offer a pelvic exam with a speculum
16:32 --> 16:34to visualize the cervix in order to
16:34 --> 16:36see whether or not there's any obvious
16:36 --> 16:38abnormality suggestive of a cancer.
16:38 --> 16:41Very often a biopsy will be
16:41 --> 16:42undertaken at that point,
16:42 --> 16:44which can usually be accomplished in
16:44 --> 16:46the office and that pathology and that
16:46 --> 16:48result will help us better understand
16:48 --> 16:50if those bleeding symptoms were
16:50 --> 16:53related to a cervical cancer or not.
16:53 --> 16:55And generally at that point,
16:55 --> 16:57whether based on the suspicion of
16:57 --> 16:59the exam or whether the gynecologist
16:59 --> 17:01would like to wait for the results
17:01 --> 17:02of the pathology,
17:02 --> 17:04they'll then refer that patient on
17:04 --> 17:07to someone like myself or our team
17:07 --> 17:09within the GYN group in order
17:09 --> 17:11to better understand the stage and
17:11 --> 17:13treatment options for that patient.
17:13 --> 17:15How are patients staged? I mean,
17:15 --> 17:17is this a series of imaging tests?
17:18 --> 17:20Exactly, we stage these
17:20 --> 17:22patients clinically meaning we don't
17:22 --> 17:24necessarily need to perform an operation.
17:24 --> 17:27And in order to understand this stage,
17:27 --> 17:29historically
17:29 --> 17:31we would do exam under anaesthesia.
17:34 --> 17:37But now we have really high quality
17:37 --> 17:40imaging options and we partner with
17:40 --> 17:42our radiology colleagues to generally
17:42 --> 17:44perform an MRI and a PET scan.
17:44 --> 17:46The MRI is important to better understand
17:46 --> 17:49the size and local features.
17:49 --> 17:51Local meaning within the
17:51 --> 17:53cervix of the tumor and then the PET
17:53 --> 17:56scan helps us ensure or detect any
17:56 --> 17:58signs of metastatic disease outside of
17:58 --> 18:00the primary tumor within the cervix.
18:00 --> 18:03Once we have all of that information,
18:03 --> 18:05we sit down as a multidisciplinary
18:05 --> 18:07group and review those results
18:07 --> 18:09and then we can better understand
18:09 --> 18:12which options that would be best
18:12 --> 18:13for each individual patient.
18:14 --> 18:17Take us through the options,
18:17 --> 18:20what on the table when it comes
18:20 --> 18:22to treatment of cervical cancer.
18:22 --> 18:23A lot of this depends on,
18:23 --> 18:25you know, each individual patient,
18:25 --> 18:27their age and what their goals are.
18:27 --> 18:28And so, you know,
18:28 --> 18:30we do unfortunately see some
18:30 --> 18:31of these cancers occurring
18:31 --> 18:33in women of reproductive age,
18:33 --> 18:35perhaps those who have either not
18:35 --> 18:38had an opportunity to carry a child,
18:38 --> 18:39if that's within their family
18:39 --> 18:41plan, or whether they're hoping to
18:41 --> 18:43have more children down the road.
18:43 --> 18:45But are faced with this diagnosis.
18:45 --> 18:47So the first thing they understand is
18:47 --> 18:49does this patient have an interest
18:49 --> 18:51in preserving her fertility options?
18:51 --> 18:53We do know that for certain cancer
18:53 --> 18:56stages or sizes of the tumor
18:56 --> 18:57and in certain patients,
18:57 --> 18:59a fertility sparing approach is very
18:59 --> 19:01reasonable and seems to have the
19:01 --> 19:03same long term oncologic outcomes,
19:03 --> 19:04which is important.
19:04 --> 19:05Obviously that pregnancy would be
19:05 --> 19:07considered high risk down the road and
19:07 --> 19:09there may be some issues in getting pregnant.
19:09 --> 19:11We've got many years worth of data
19:11 --> 19:14now to so show that in certain women
19:14 --> 19:16those options are reasonable and they
19:16 --> 19:18do not have to compromise their
19:18 --> 19:20oncology outcomes just for fertility.
19:20 --> 19:22So it's been a very exciting advance
19:22 --> 19:23in the field for those women who
19:23 --> 19:25are not interested on preserving
19:25 --> 19:27their fertility or may not have
19:27 --> 19:28that option based on the results of
19:28 --> 19:30those tests that we talked about,
19:30 --> 19:31we then have to decide,
19:31 --> 19:33is this a woman who would be
19:33 --> 19:35best served with surgery,
19:35 --> 19:36meaning radical hysterectomy
19:36 --> 19:37to remove the uterus,
19:37 --> 19:39cervix and tumor or do we think
19:39 --> 19:42that this cancer will be best
19:42 --> 19:44controlled with a combination of
19:44 --> 19:45chemotherapy and radiation?
19:45 --> 19:47And a lot of that depends on
19:47 --> 19:49the size of the tumor,
19:49 --> 19:50some of the information we get
19:50 --> 19:52from the pathology in our exam,
19:52 --> 19:53in the office.
19:53 --> 19:57And so for women who do want
19:57 --> 19:59to preserve their fertility,
19:59 --> 20:01clearly the radical hysterectomy
20:01 --> 20:04is not a viable option.
20:04 --> 20:06So what does their treatment
20:06 --> 20:08algorithm kind of look like?
20:09 --> 20:11Right, so we do what is called
20:11 --> 20:12a radical trachelectomy,
20:12 --> 20:15which is a procedure to remove the cervix
20:15 --> 20:18and the tissue surrounding the cervix.
20:18 --> 20:19We also sample some lymph nodes
20:19 --> 20:21at the same time to make sure
20:21 --> 20:22that cancer has not spread.
20:22 --> 20:24What we do then,
20:24 --> 20:26after the cervix has been removed is
20:26 --> 20:28reconstruct the uterus to the top of
20:28 --> 20:31the vagina and place a device there
20:31 --> 20:33called a circlage which helps prevent
20:33 --> 20:36any dilation of the lower portion
20:36 --> 20:38of the uterus during the pregnancy.
20:38 --> 20:40It appears that this is a safe
20:40 --> 20:42option for women who who want
20:42 --> 20:43to choose this approach,
20:43 --> 20:45but as you can imagine there will be
20:45 --> 20:47some challenges with the fertility.
20:47 --> 20:47I'm sorry,
20:47 --> 20:49with the pregnancy and will need to
20:49 --> 20:52be closely monitored by a high risk team.
20:52 --> 20:54But it appears that this surgery can
20:54 --> 20:57be performed safely from a vaginal,
20:57 --> 20:59laparoscopic or even a traditional
20:59 --> 21:01open laparotomy approach.
21:01 --> 21:02And patients tend to
21:02 --> 21:03do well in the long term.
21:04 --> 21:07Is this a longer or more complicated
21:07 --> 21:10procedure than the radical hysterectomy?
21:10 --> 21:12Yeah, it can be a little bit
21:12 --> 21:14longer and more complex.
21:14 --> 21:17And that's why we certainly encourage
21:17 --> 21:20patients to see a group or a team
21:20 --> 21:22with expertise in this procedure.
21:22 --> 21:25But for those who do undergo the surgery,
21:25 --> 21:26they appear to have
21:26 --> 21:28comparable oncologic outcomes and have
21:28 --> 21:31gone on to carry children down the road,
21:31 --> 21:33which is always exciting to see those
21:33 --> 21:34pictures in the office when patients
21:34 --> 21:35come back to see us and follow up.
21:36 --> 21:40Yeah, I'm sure for the patients
21:40 --> 21:43for whom fertility is not a major concern,
21:43 --> 21:46you mentioned that there were two options.
21:46 --> 21:48One was the radical hysterectomy and the
21:48 --> 21:51other was chemotherapy and radiation.
21:51 --> 21:53Are those two equivalent oncologically?
21:54 --> 21:56That's a great point and I bring that
21:56 --> 21:58up with my patients when I talk to
21:58 --> 22:00them because they do appear equivalent.
22:00 --> 22:02And what we're trying to do is
22:02 --> 22:04identify patients who would not
22:04 --> 22:06necessarily require adjuvant treatment.
22:06 --> 22:09Meaning if someone is going to have surgery,
22:09 --> 22:11we want to ensure that then after the
22:11 --> 22:13surgery there's no indication to give
22:13 --> 22:15radiation after because we know the
22:15 --> 22:17toxicity and side effects are worse if
22:17 --> 22:19patients need a surgery and then we
22:19 --> 22:21know they need radiation in addition to that.
22:21 --> 22:23So we try to pre select patients
22:23 --> 22:25to either need one or the other.
22:25 --> 22:26For some reason,
22:26 --> 22:29patients often perceive radiation or
22:29 --> 22:31chemotherapy as maybe not curative or
22:31 --> 22:34I'm just trying to palliate this cancer.
22:34 --> 22:35That is really not the case in
22:35 --> 22:37cancer of the cervix.
22:37 --> 22:39And we treat with a curative intent to
22:39 --> 22:42make these cancers go away long term.
22:42 --> 22:44So I try to help patients understand
22:44 --> 22:47that we want to select an individualized
22:47 --> 22:49treatment plan that is best suited
22:49 --> 22:51for their individual scenario.
22:51 --> 22:53And if that plan is radiation
22:53 --> 22:54to chemotherapy,
22:54 --> 22:56they should not feel that
22:56 --> 22:57they're somehow being,
22:57 --> 22:58you know,
22:58 --> 22:59put into a category that will not
22:59 --> 23:02have the same outcomes of a patient
23:02 --> 23:03undergoing a surgical approach.
23:04 --> 23:07So if they're equivalent, why would
23:07 --> 23:10anybody do the radical surgery?
23:10 --> 23:13For the smaller tumors,
23:17 --> 23:19they have one operation that tends
23:19 --> 23:21to be a little bit less in terms
23:21 --> 23:23of toxicity to the other pelvic
23:23 --> 23:25structures because radiation can
23:25 --> 23:27have some side effects on the bowel.
23:27 --> 23:29The bladder patients may experience some
23:29 --> 23:32long term issues in terms of diarrhea
23:32 --> 23:34or constipation or bladder irritation.
23:34 --> 23:35In terms of toxicity,
23:35 --> 23:37there certainly can be more toxicity
23:37 --> 23:39with the radiation approach,
23:39 --> 23:41but when looking at the long
23:41 --> 23:42term oncologic outcomes,
23:42 --> 23:43they appear equivalent for
23:43 --> 23:46certain stages of this cancer.
23:46 --> 23:48Obviously if we find on the PET
23:48 --> 23:50scan that the cancer is spread
23:50 --> 23:52outside of the pelvic area,
23:52 --> 23:54then neither surgery or radiation
23:54 --> 23:56are necessarily indicated.
23:56 --> 23:58And we often choose a combination
23:58 --> 24:01of chemotherapy and some of these
24:01 --> 24:02newer agents like immunotherapy
24:02 --> 24:04which many patients are asking about.
24:04 --> 24:06And it's been very sort of present
24:06 --> 24:09in the media and we're very
24:09 --> 24:11excited to see that a lot of these
24:11 --> 24:13immunotherapies and new drug
24:13 --> 24:15developments are showing promise in cancer of
24:15 --> 24:16the cervix as well.
24:16 --> 24:18So I want to get to the drugs
24:18 --> 24:20in a minute, but just to finish
24:20 --> 24:22up the conversation with regards
24:22 --> 24:25to fertility preservation and the
24:25 --> 24:27different options for women who do
24:27 --> 24:29want to preserve their fertility,
24:29 --> 24:33is chemotherapy and radiation therapy an
24:33 --> 24:36option if they choose to, for example,
24:36 --> 24:40harvest their eggs or ovarian
24:40 --> 24:42tissue prior to the chemotherapy and
24:42 --> 24:44radiation and that way they could
24:44 --> 24:46avoid the more complicated surgery?
24:46 --> 24:49Absolutely. The retrieval of the eggs
24:49 --> 24:51is certainly possible and we have
24:51 --> 24:53a wonderful group of reproductive
24:53 --> 24:54endocrinologists that we work
24:54 --> 24:57closely with who get patients in
24:57 --> 24:58quickly to stimulate an ovarian
24:58 --> 25:01cycle and retrieve those eggs.
25:01 --> 25:03Now, if patients go on to receive
25:03 --> 25:04the radiation and chemotherapy
25:04 --> 25:05after the egg retrieval,
25:06 --> 25:07the uterus will unfortunately
25:07 --> 25:09not be able to function in the
25:09 --> 25:11capacity to carry a pregnancy.
25:11 --> 25:13But patients would have the option
25:13 --> 25:16to use those harvested eggs with a
25:16 --> 25:18gestational carrier or surrogate to
25:18 --> 25:21carry a child that is genetically theirs.
25:21 --> 25:21But unfortunately,
25:21 --> 25:24the radiation does do damage to the
25:24 --> 25:26uterine structures in terms of its
25:26 --> 25:29ability to carry a pregnancy down the road.
25:31 --> 25:35So moving on to the patients who have
25:35 --> 25:37metastatic cancer for whom chemotherapy
25:37 --> 25:40or immunotherapy are indicated,
25:40 --> 25:43can you first of all tell us a little
25:43 --> 25:46bit about how many patients or what
25:46 --> 25:48proportion of patients with cervical
25:48 --> 25:50cancer present with metastatic
25:50 --> 25:52disease versus non metastatic and
25:52 --> 25:54and what's their prognosis like?
25:55 --> 25:58Yes. Fortunately we do not see a
25:58 --> 26:00high number of patients.
26:00 --> 26:01We're probably talking in the order
26:01 --> 26:04of five to 10% who are presenting
26:04 --> 26:05with metastatic disease when they
26:05 --> 26:07first show up to the clinic.
26:07 --> 26:09And this is likely due to
26:09 --> 26:11our excellent screening and patients
26:11 --> 26:13being aware of the symptoms to get care
26:13 --> 26:16to detect disease in its earliest stage.
26:16 --> 26:18But when these patients do show up,
26:18 --> 26:19you know for years we did not have
26:19 --> 26:21much in terms of options to offer them.
26:21 --> 26:23Cytotoxic chemotherapy was really
26:23 --> 26:26all that we had and prognosis
26:26 --> 26:28was not great for those patients.
26:28 --> 26:31We're very excited to see the rapid
26:31 --> 26:33expansion of drug development in the
26:33 --> 26:35cervical cancer space even over the
26:35 --> 26:38last three to four years where we
26:38 --> 26:40have seen a number of new approvals
26:40 --> 26:42and really ongoing interest and
26:42 --> 26:44excitement in additional clinical
26:44 --> 26:47trials that will hopefully see
26:47 --> 26:49these drugs brought into the ovarian
26:49 --> 26:51cancer space to help more women.
26:52 --> 26:54Can you talk a little
26:54 --> 26:56bit about some of the ongoing
26:56 --> 26:57clinical trials and research
26:57 --> 26:59that you're most excited about?
27:00 --> 27:01Yeah, absolutely.
27:01 --> 27:03You know like all cancers we often
27:03 --> 27:06see the new drugs develop for patients
27:06 --> 27:08you know later in their cancer
27:08 --> 27:10journey and it takes some time for
27:10 --> 27:13those medications to trickle into
27:13 --> 27:16the earlier phase of cancer treatment.
27:16 --> 27:18And so use of immunotherapy
27:18 --> 27:20in the earlier elements,
27:20 --> 27:23meaning not waiting for
27:23 --> 27:25recurrence or maybe in patients
27:25 --> 27:27who have a tumor that is perhaps
27:27 --> 27:28too big for fertility sparing.
27:28 --> 27:30But maybe we can use an immunotherapy
27:30 --> 27:33to shrink that down and then offer
27:33 --> 27:34patients a fertility sparing option.
27:34 --> 27:37I think would be very exciting
27:37 --> 27:38because with immunotherapy we really
27:38 --> 27:41see a difference in the side effect
27:41 --> 27:43profile for patients as well.
27:43 --> 27:44So it's not just about the
27:44 --> 27:46long term cancer outcomes,
27:46 --> 27:48but how patients feel their quality
27:48 --> 27:50of life and their experience
27:50 --> 27:52during their cancer care.
27:52 --> 27:54And immunotherapy seems to be
27:54 --> 27:56offering patients a different but
27:56 --> 27:58in somewhat improved side effect
27:58 --> 28:01profile when we compare it to
28:01 --> 28:02some of the older chemotherapies.
28:02 --> 28:03Other than that,
28:03 --> 28:06we're excited to see some updated
28:06 --> 28:08cervical surgery trials that have
28:08 --> 28:10been presented in conference format
28:10 --> 28:12to suggest that maybe for certain
28:12 --> 28:14women the radical surgery is not
28:14 --> 28:17necessary anymore and we can do a
28:17 --> 28:20smaller less invasive hysterectomy,
28:20 --> 28:22but confer a similar long term
28:22 --> 28:24outcome for those women.
28:24 --> 28:26And that would be a real game changer
28:26 --> 28:28in the surgical treatment of this cancer.
28:28 --> 28:29So we look forward to that
28:29 --> 28:30publication coming up soon.
28:31 --> 28:32Doctor Mitchell Clark is an
28:32 --> 28:34Assistant professor of Obstetrics,
28:34 --> 28:36Gynecology, and Reproductive Sciences
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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Cervical Cancer Awareness Month with guest Dr. Mitchell Clark January 21, 2024

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Dr. Mitchell Clark

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