#10: Cervical Cancer is a known STI

Simply Hormones Podcast

My interview with Gill Burgess tells you everything you ever wanted to know about this silent killer; cervical smears – why they’re important and much much more. Gill Burgess is the Cancer Screening Co-ordinator for Croydon PCT, specialising in Breast, Bowel and Cervical Cancers.

Gill is innovative and forward thinking – just listen to what she has to say and the full transcript appears below.

Interview with Gill Burgess on Cervical Cancer

KC: Hello everyone, it's Kathryn Colas here from SimplyHormones.com and I'm here today talking to Gill Burgess, who's a Cancer Screening Co-ordinator for Croydon PCT (NHS Primary Care Trust) and her speciality is breast, bowel and cervical cancer, and we're going to be talking to Gill this morning on cervical cancer to see if we can find out some more about it. So good morning to you Gill.

GB: Good morning.

KC: We're going to be talking about cervical cancer, and I think the first thing our listeners would like to know is what is it exactly?

GB: Well, it's the most common cancer affecting women in developing countries Kathryn, and it's caused by Human Papilloma Virus, which is an infection of the cervix. It's associated with cellular changes which can be detected early on under microscopic examination; for example the smear test. HPV infection usually clears within a few months, I think it's about 90% within 2 years. The problem is it's persistent infection beyond 12 months which is associated with the high risk of cervical cancer.

KC: And who is most at risk?

GB: It's transmissible mainly in the younger age group. You find most of it in women under the age of 30, but it's younger people that will pick up this virus. It's a very transient virus and it just goes from one to the other very very quickly, but like all viruses they move on as well, it's those, that as I said earlier, that persist that create the problem of cervical cancer. And only a very small proportion will go on to develop the cancer as well.

KC: So it's still quite rare in a sense?

GB: Yes the risk infection is soon after sexual activity begins. In some populations there is another peak among women actually at the menopause in older women, and although HPV is sexually transmitted, penetrative sex is not required for transmission. Skin to skin genital connections, penile to vulva for example, contact is a well recognised mode of transmission.

KC: That throws a different light on it, doesn't it?

GB: Yes, I think some data was brought up a while back on age specific prevalency of HPV, suggesting that there's a pattern of infection between regions and socio- economic groups. Also HIV infected individuals are at a higher risk of HPV infection. And they can be infected by a broader range of HPV types. So if you've got HIV you've got a low immune system and you're very sexually active with different partners, then you are at a much greater risk.

KC: I've also, continuing on risk, I've read some research that says the pill could increase the risk. Do you have a view on this?

GB: Yes, there are risks to the pill. It is actually one of the contributing factors alongside having a lot of children, at the early age of the first sexual activity. Cigarette smoking is another huge factor. And long term use of the pill, you're absolutely right, it is another risk along with co-infections like Chlamydia, because persistent infection, again, this is the risk factor. And the peak prevalence of the infection is in women under the age of 30, and, as I said earlier, those that are actually over the age of 50 going through the menopause.

KC: So you say long term use of the pill, what would you describe as long term?

GB: They won't give the pill to obese women, or women who are over the age of 35 or women that smoke, because there are risk factors involved, but to me the pill is a better scenario than getting pregnant, because pregnancy is the biggest risk factor of all. So the pill is a contra-indication, a slight one, but then so is smoking. Smoking is a huge risk.

KC: And it's better to stop smoking. It's all relative isn't it? You've just got to take a balanced view, because all drugs have side effects of some kind or another and you've just got to work out whether the benefits are greater than the risks.

GB: If you put somebody on the pill you've got look at their risk factors. You can ask the question about sexual activity, I don't know whether I would. If you get a girl in who wants to go on the combined or contraception pill and she is a smoker and you can talk sexual history to her, you could say “well actually the pill is a risk factor” and you could offer alternative methods of contraception. But there is a way round it. But as you said quite rightly, smoking is what we need to get rid of first and foremost.

KC: Yes, that's a killer for everything, a big no, no! Just touching again on the over 50 age group, which of course is what I fall into and post menopausal women, I don't think women of that age group fully understand why they have suddenly become vulnerable and of course it's because the divorce rate is now much higher within that age group so of course they're changing partners and exposing themselves to the same risk.

GB: They are Kathryn yes, you're absolutely right. And I think you've got to look at the screening and the risk factors to women over the age of 50 and then tame the screening programme actually to individual needs and it is all about divorce rate and women becoming more sexually active. Woman today have a lot more sexual freedom and they are very happy to have much fuller and richer lives than our previous generations did.

KC: So just when they thought they could throw the whole thing wide open and say “yippee” now there's no risk of pregnancy and all the rest of it, all of a sudden they've still got to be careful of who they have sexual relations with because this is a sexually transmitted disease, as we've already discussed.

GB: And another consideration of course is that men are also becoming more sexually active. We're not taking into consideration what the men are doing as well. Because men have got more money at retirement age haven't they? And they're meeting older women and so that's something else we need to be thinking about really. At what age should we stop doing cervical screening? Should we extend it into the older age group? I know that some research has been done on that in the last couple of years but that again comes with its own little set of risks because if you start taking smears from women that are over age 65, you've then got the problem that it's difficult to take a smear from a woman who's over 65, because she's got the risk of vaginal atrophy, then you're going to a whole new world aren't you.

KC: I'll just explain to our listeners a bit about that. That's vaginal dryness. I'm always standing on my soapbox about this, as you know Gill, because it's not really addressed properly in the doctors surgery, if women ever get that far because it's such an embarrassing subject, it's usually when they go for a cervical smear that the problem arises because the swab can't take the test.

GB: Yes, that's right.

KC: But touching on the screening programme, there is a national screening programme in place for cervical cancer, so it sounds to me like there's a fixed age group at the moment, is there?

GB: There is, it's 25 to 65.

KC: So it's quite broad then.

GB: It is, we stopped screening under 25s, five years ago, although there is some controversy about it, because girls, if they've had early sexual relations and they've had a few partners, they feel that they ought to have a screening test done and it can be quite controversial and it took us a long time to get over to people that this is a screening programme, it's not a diagnostic test and so we have to be looking at signs and symptoms and I see many girls in my clinic, saying to me “please Gill can we please just do the smear test”. I'm a great believer is educating women so I spend a lot of time showing them pictures and demonstrating exactly why we're doing it, what we're doing and what the outcome is and if they've got symptoms then we look at why. Why have they got bleeding in-between periods, or they might have another infection. It might be that they have missed the pill or the pill packet is out of sync. There are different reasons, so you would then refer these women to the GUM (Genito Urinary Medicine) clinics or the GP who can take swabs from these women to test for sexually transmitted infections and that has to be ruled out. The answer is not to get a woman in when she's 22 to start taking a smear test.

KC: It comes back to this, where we are in society at the moment, that we rush off to the doctor as soon as something is wrong and ask for a magic pill and we've just got to recognise our own bodies more, understand what's going on, and with people like you teaching us how to recognise things, and what we can do about it.

GB: That's absolutely right and the cervix doesn't actually mature until the girl is probably 20-21 so if you start taking smear tests under that age you will automatically get an abnormal smear result in most cases.

KC: So it's not helpful is it?

GB: It's not helpful at all, it creates huge amounts of anxiety within the girl and the mother, or the parents, or whatever. It's a really difficult situation sometimes, but it's educating people, it is all about that and lots of explanations.

KC: Gill, can you describe to us what actually happens in a smear test? They're called up for a smear test, they go along to the clinic for their appointment, and I know lots of girls and women might be very nervous about what's going to happen next.

GB: I opened my own cytology clinic (cytology: the study of cells), a womens health clinic almost 8 years ago, as an alternative to a GP and the reason I talk about that is because I worked in a nurse-led scenario, on a huge housing estate, looking after many single women and their children, and one of the things I found was that the women were never having their smear tests done because they were so terrified of the smear test, and it could have been due to child abuse or rape or domestic violence, whatever. And these women were the women not coming for smears and I was very agitated by that because I couldn't understand what the problems were. So I was hell bent on educating them and then several years later I was given this wonderful opportunity. I put in a business plan to my PCT and said “let me have an alternative to a GP practice.” So I opened my own clinic and I went off and did psycho-sexual training in London and I was able to recognise why these women don't want to have their smears, and as I said earlier it's all based on fear and lack of understanding. So what my clinic offers them is time, and there's comfort and we have long chats, and if they come and they're terrified, it can take up to something like 4-6 sessions to take the smear, but we find out what the problem is. So when they arrive, providing it's a nice normal scenario when women arrive for their smear, you explain the procedure, you do a sexual history, you talk about their menstrual cycle, the children that they have. You talk about what contraception they're using and I always ask the question “do you know why we take the smear?” and 90% of them will say ”well it's a test for cancer”, but of course it isn't a test for cancer, it's a screening programme. And then I will bring out my little pictures, I'm a great one for pictures, and show them where I'm taking the smear from, what's happing in that little corner and what the results are likely to be. And then I'll explain that they will have a letter from me, or their GP, or the screening programme, very quickly, to tell them what the result is. I show them where they have to lie, it's all very private and confidential and then the smear is taken and it's a very easy insertion of a speculum and then you just quietly take cells using a very soft brush. The cells are put into a pot and they are sent off to the laboratory. It's a great opportunity for women to discuss all areas of their sexual life if they want to, anything they are unsure about.

KC: I think that's very helpful Gill, because I think so many women think that when you're going for the cervical smear, as you said, we think it's to see if we've got cancer or not, but you're just testing for abnormal cells, and when you find those abnormal cells you can take action to clear those abnormal cells. It's not cancer.

GB: I always say to women if you found a lump either in your breast, or your nose, your ear or wherever, you'd go and show somebody. But down there you can't see a damn thing, you know you can't see anything, so we take cells to have a look at what the changes might be. It's a screening programme, it's excellent. Well worth doing.

KC: And you've also explained in there, you get people that don't turn up for their appointments?

GB: Oh yes, the DNA (did not arrive) rate in my clinic is pretty high actually, so we have shortened appointments, but women get very fearful, of course if women have got their period it's not useful to take it then, and you can't take a smear on anybody who has just had a baby, you have to wait till they are 3 months post natal, because hormones need to go back (to normal), but culturally women don't agree with it, there are certain cultures that don't think it's a good idea. And of course many cultures are not sexually active and don't want to have smears and we have to recognise that as professionals, it is a screening programme, it's patient choice isn't it? And it's about recognising that the opportunity's there and if you want to take it you can, so professionals have to be very careful that we're not forcing the issues, if you understand what I mean?

KC: Yes quite, but it's in your own best interest to take part really isn't it?

GB: That's right, absolutely.

KC: And finally Gill, you've mentioned the HPV, the human papilloma virus as being a major cause of cervical cancer. Would you like to say something about the vaccination that is now available and how it helps, etc?

GB: Yes, it came out about 2007, 2008 I think. There were two types of vaccines. As we said earlier, one of them looked at four different types of virus and the other one, two. And we chose Cervarix, because, although it covers two viruses it was the one that has had the longest evidence from America, it's now up to 8 years, whereas the Guardasil didn't have the amount of evidence. A lot of people thought it was about costing, which one we would use, but in fact it wasn't, it was just that the Cervarix had a longer evidence-base against it in America, so that's why it was chosen. It's actually given to young girls between the ages of 12 and 13 and they get three doses over a six month period. They (the researchers) are constantly looking up all the information on this file, the evidence goes on all the time in America.

KC: I think I'd like to add in there, if the girls miss that vaccination at 12 or 13 is it recommended that they have it later on, or what happens then?

BG: They can have catch up on it. It was recognised I'm sure that it was not cost effective to run a national vaccination programme for women over the age of 18, which is because as soon as the woman has started to have a sexual life is at risk of catching the virus anyway. And women not covered by the vaccination programme will still be invited to be screened routinely as part of the programme. Tests for HPV vaccination exist but these are primarily for use for research purposes and not normally available on the NHS, but I know that there's a lot of work being carried out on that.

KC: And I also think another key area is what you've just said, that those girls that are invited for vaccination aged 12 & 13 will also be on the screening programme at the relative time later on, it doesn't mean just because they've had the vaccination they don't need screening any more, I think that's very important too.

GB: Yes. It's my granddaughters that will be the beneficiaries, I feel, of all of this, it's not going to be immediate. It doesn't mean to say that were going to stop taking smears because of the vaccine. The largest bonus for me is that it's the first vaccine against cancer and that's got to be a real bonus hasn't it?

KC: Definitely, yes.

GB: Absolutely.

KC: Something that can really help and my very last question to you today Gill, is to do with sexual discrimination! The HPV virus as we know is a sexually transmitted infection and it seems to me that what's good for the gander is good for the goose, so why aren't the boys in on the vaccine programme?

GB: Well I think the thing to remember is that because it's a relatively new vaccine, there's insufficient evidence to know what would happen to boys. There's also a cost issue as well, but also vaccinating the girls will also reduce the transmission to the boys won't it? So there is that school of thought. And this should lead to the reduction in rarer forms of cancer caused by HPV in both boys and girls, so I think with all of this, cost is the thing. I'm sure in America they'd love to vaccinate the boys and yes if it goes out there it will probably come over here, but at this point in time it's still very new and we're still learning a lot, but you're quite right as far as sex discrimination is, why not? Perhaps we should have given it to the boys first?

KC: Listening to you speaking perhaps the boys need a slightly different vaccine, because of course they don't have the same hormone structure as girls. It may be a whole different ball game for them altogether.

GB: Yes that's right, but certainly vaccinating the girls will reduce the rarer forms of the cancer, which is the big bonus isn't it?

KC: That's brilliant. Thank you so much for that Gill, we've covered so much today and I think I must just reinforce to tell everybody to turn up for their cervical smear when they're called forward.

GB: I have a very good motto actually you know: ‘never fear to have a smear'.

KC: I like that.

GB: It's not as painful as people think; it's just that it is about looking after yourself.

KC: And not worrying unnecessarily.

GB: That's right, absolutely.

KC: Well, thank you very much Gill.

GB: Thank you Kathryn.

KC: It's just been brilliant speaking to you and I'm sure that this information that we've discussed this morning will be of help to a lot of women.

For further information on this subject please go to http://cancerhelp.org.uk and http://www.patient.co.uk/health/Cancer-of-the-Cervix.htm. For more information on any aspect of menopause, please visit http://www.simplyhormones.com.

This interview was brought to you by Kathryn Colas of SimplyHormones.com

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