Cervical Cancer Screening Guidelines – Role of HPV Testing

The American Cancer Society says women over 30 years old who have had three normal Pap smear test results in a row can get screened every 2-3 years rather than annually. They can be screened with a conventional Pap smear test or a liquid based Pap test or the HPV (Human Papilloma Virus) test.

A recent study at Kaiser Permanente Northern California from 2003 through 2005 suggested that HPV (Human Papilloma Virus) testing may be more accurate than Pap smears. Their analysis showed that:

>  For all women with a normal Pap smear test there were 7.5 cervical cancers detected per 100,000 woman/ years.

>  For all women who were HPV-negative the rate was 3.8 cervical cancers per woman/years.

>  For women who were both HPV-negative with normal Pap smears the rate was 3.2 cervical cancers per 100,000 woman /years.

Hormuzd Katki, PhD, of the National Cancer Institute in Bethesda, Maryland recognized the increased accuracy of HPV testing over Pap testing but encouraged co-testing.

“ Most women still undergo annual screening out of habit” according to Brent DuBeshter, M.D. of the University of Rochester Medical Center in Rochester NY. Even stranger is the case of women post hysterectomy with no cervix continuing to see their gynecologists on an annual basis for pap testing?

The recommendation for annual pap smears had been present for so many years that many doctors and patients aren’t “comfortable with the new guidelines that call for screening every three years in those at low risk for cervical cancer” according to DuBeshter.  “Many providers have a hard time changing habitual practice and adopting new evidence and practice guidelines,” says Ranit Mishori, M.D. of Georgetown University School of Medicine.

What is clear is that screening every three years in low risk patients works. What will need to be determined is the evidence based role of HPV testing in conjunction with, or as a replacement for, Pap smears.

Non Steroidal Anti-Inflammatory Drug (NSAID) Use and Heart Attacks

Most of us weekend warriors are used to reaching for the ibuprofen , naproxen or aspirin for relief from aches and pains after some strenuous gardening, yard work or recreational exercise. It helps alleviate the pains and allows one to go on with their life and perform the normal activities of daily living.

For many individuals with advanced osteoarthritis or the more severe types of immunological arthritis such as rheumatoid arthritis or psoriatic arthritis, these medicines are liberating and allow patients to live a normal life. For many years the major concern with these medications was their effect on the stomach causing irritation, inflammation and gastrointestinal bleeding. Then experts issued warnings about long term use and liver and kidney damage.  These side effects were listed on the product insert and were not unexpected.

What was unexpected was the association of NSAID’s and acute heart attacks. Drugs like Vioxx and Bextra, which were extraordinarily effective at relieving aches and pains, were pulled from the market after being determined to dramatically increase the number of acute myocardial infarctions users suffered. The NSAID’s reduced joint pain and inflammation by inhibiting chemicals called prostaglandins. Unfortunately the same inhibition of prostaglandins that produced less inflammation and joint pain also inhibited prostaglandins that kept our coronary arteries from going into spasm and cutting off the circulation to our heart muscle. For several years now pharmaceutical manufacturers have been looking for the perfect formula that inhibits joint inflammation without increasing heart attack risks.

A recent study from Denmark indicated that their search has not yet been successful. Denmark maintains detailed records of patient hospital admissions and medication usage as well as a central national death registry.  Using these data bases, the records of 84,000 patients admitted to a hospital for treatment of a myocardial infarction from 1997-2006 were reviewed and linked to pharmacy records. Researchers found that 43.3% of the MI patients received NSAID’s post MI and there were 35,257 deaths or repeat heart attacks.

“Overall NSAID treatment was related to a significantly increased risk of death at the beginning of the treatment and the risk persisted throughout the treatment. Patients taking Celebrex had an increased risk of death when the treatment lasted two weeks to a month.  All NSAID’s increased the risk of death or recurrent MI by 45% after a week.  Naproxen increased the risk of death or recurrent MI by 76% after a week. For treatment lasting 30-90 days the increased risk was 15%.  Ibuprofen had the lowest initial risk, just 4% increase for treatments lasting seven days or less.

In practical terms, we must limit NSAID use to the absolute minimum in patients with established cardiovascular disease.  Based on this article, ibuprofen seems to be the best choice for short term use in patients with known cardiovascular disease. Patients with cardiovascular disease and known previous MI should be talking to their doctor before they reach for the over-the-counter bottle of a NSAID.

Smoking Increases the Risk of Breast Cancer, Lung Cancer and Colon Cancer in Women

The Surgeon General of the United States issued another report on the dangers of smoking and its addictive potential last year.  At the time of release I was quite skeptical about the cost of the report and the need to remind Americans again that smoking is dangerous for you.  Then along comes a detailed review of the National Surgical Adjuvant Breast and Bowel Project. According to Stephanie Land, PhD, of the University of Pittsburgh, long-time smokers had a 59% increase in the risk of invasive breast cancer compared with nonsmokers.  The study looked at the links between four types of malignancy: breast, lung, colon, and endometrial cancer with smoking, alcohol use and leisure time activity.  The findings suggested that:

1.       Women who had smoked between 15 and 35 years had a 35% increase in the risk of breast cancer compared to non smokers. In that same group, if a woman smoked more than a pack a day she had a five – fold higher risk than non smokers.

2.       Women who had smoked 35 years or more had a 59% increase in the risk of breast cancer. These long-term smokers had a 30 times higher risk of lung cancer than non smokers.

3.       The risk of colon cancer among long–term smokers was five times higher than among non smokers.  A drink of alcohol a day reduced the risk of colon cancer by 65% compared to non drinkers.

4.       Inactive women had a 72% increased risk of uterine endometrial cancer compared to active participants in the study.

The study of almost 14,000 women highlighted the benefits of improving life style choices.  While researchers search for drugs and medication to prevent these life threatening illnesses, the study pointed out the benefits of altering the life style choices of women to prevent the development of cancer.

It is clear that smoking prevention and smoking cessation programs can do far more to prevent these cancers than pharmaceuticals. With cutbacks on funding for public health and the elimination of most health and hygiene classes in middle schools and high schools due to financial constraints, I wonder if we are being penny wise and pound foolish.