the answer is 11,900.

It’s my favorite question to ask.  “How many women are diagnosed with cervical cancer annually in the United States?”

I ask it almost weekly to a medical student or a resident.  I’m not sure why or when it became my favorite question to ask.  Maybe because the answer keeps being the same.  Maybe because it launches me into one of my favorite lectures about how we have failed to eradicate an almost absolutely preventable disease.  Probably because I don’t think I will reduce these cancers so much as will my students and residents as they become advocates in their practices and communities for gynecology cancer awareness and prevention.

September is Gynecologic Cancer Awareness month. Thousands and thousands of women will be affected with gynecologic cancer each year.  Many of them don’t know the signs and symptoms of Gyn cancer, they don’t have access to screening for these cancers or they  aren’t aware that they are at risk.  A few facts you should know about Gynecologic Cancers.

  • A woman can be affected with cancer of the ovary, uterus, cervix, vagina or vulva
  • Cancer in each of these organs can occur as different types and those different types of cancer may have different risk factors
  • As women age their risk for gynecologic cancer increases.
  • About 45,000 women will be diagnosed with uterine cancer, 20,000 with ovarian cancer, almost 12,000 with cervical cancer, and about 6,000 with vaginal or vulvar cancer.
  • Many if not most cervical, vaginal and vulvar cancers can be prevented by vaccinating young men and women against HPV.
  • Uterine cancer is associated with obesity and excess estrogen.  Abnormal bleeding is the most common symptom.
  • Most women with ovarian cancer are diagnosed at a late stage due to the lack of a reliable screening test and its vague symptoms.
  • The later stage the gynecologic cancer is diagnosed the more likely the woman is to die from her disease.

Most of my clinical work with cancer centers around the prevention of lower genital tract disease.  Cervical, vaginal and vulvar dysplasia and cancer.  I started working in this area in residency and was given opportunities by mentors and colleagues to build my knowledge and skills for patient care, research and education in this area.  But about half of my research focuses on the early detection and prevention of ovarian cancer.  The picture above is my cousin Tara.  She was diagnosed with ovarian cancer in 2012.  I remember my mom telling me that she had ovarian cancer and thinking about how impossible that seemed.  She was younger than I was and very healthy.  Tara has persevered through a massive surgery, intense chemotherapy and more surgery in addition to countless scans, doctors appointments and other medications.  Tara is the reason I love collaborating with my research partners to try and better understand how to reduce that number of ovarian cancer patients from 20,000 annually to as close to zero as possible.

So here’s the advice.  The “to do list” if you will.

Get an HPV immunization: If you are between the ages of 11 and 26, if you know or love someone between the ages of 11 and 26, if you are the parent of someone between the ages of 11 and 26 then you need to know about and advocate for HPV vaccination.  It’s the best way for us to reduce or eliminate those 11,900 cases of cervical cancer.  Plus if you don’t do anything my favorite question will never have a different answer and then how will I stump my medical students.  It’s safe.  It’s effective.  You can read more about HPV vaccination here.

Know your family history.  Some ovarian and uterine cancers are genetic in nature.  My family loves to share this kind of information.  My mom’s favorite kind of text: “Did you know so and so was in the hospital for such and such?”  This is usually followed by me asking who she is talking about and how they are related to me.  If this isn’t your family start asking questions.  Talk to your doctor about the cancers that have affected the men and women in your family and they can talk to you about genetic testing.  You can read more here.

Take care of yourself. See your doctor for regular and preventative healthcare.  It’s no fun going to the gynecologist.  I mean even I don’t love going.  But, it’s worth it.  First of all, OBGYNs are awesome.  Secondly, we can’t diagnose things we don’t see you for.  Besides seeing your doctor, exercise most days of the week, eat your veggies, don’t smoke.

Most importantly, take care of others. 

Tara has established a non-profit organization to support otscreen-shot-2016-09-02-at-6-22-54-pmhers diagnosed with cancer. You can find out more about over at Tenaciously Teal.   Tara is a huge advocate for cancer prevention, screening and early diagnosis.  As a physician I am called to improve the health of my patients.  As a Christian I am called to care for the poor, the widow, the sojourner.  I can’t do it without you. Many women I see don’t have access to healthcare.  They don’t have insurance, they live far from a healthcare facility, they don’t have transportation or childcare.  Be a voice for those who don’t have one.  Take action for someone who doesn’t have the courage.  It will take all of us to make a difference.

an ounce of prevention.

An interesting thing happened to me a few months ago on a Sunday morning.  I was doing my after church thing…which means my children run around the sanctuary like banshees and pastor Jason is talking to a hundred or so folks and no one can decide what to do for lunch.  It’s a routine of madness.  In the midst of all of that I was approached by a family in our church.  These are people I adore.  They are faithful, they are helpful, they are fun.  Their oldest has started that tortuous time we call middle school.  As a side note there are literally 10 million things I would do over again before middle school.  Like medical school, the last 4 weeks of pregnancy in the Oklahoma heat, 24 weeks of Gyn Oncology service as a resident….middle school seems like the worst thing….but back to the story.

This lovely family had visited their local pediatrician for a routine well child check.  Their pediatrician had appropriately recommend the meningococcal vaccine and the Tdap vaccine (which they happily accepted) and then something strange happened….their pediatrician then asked them to “consider the HPV vaccine…to ask their friends, to read about it, to think and let the doc know what they wanted to do.”  So they came to me to find out “why wouldn’t our doctor want our daughter to have this vaccine?  Is there something wrong with it?  What should we do?”  At this point I am making that face when you are horrified by something…the one with your eyes wide and your mouth open.  And of course I said yes..yes..yes…please go back and get the HPV vaccine series for your child!

If you didn’t know, Human Papillomavirus (HPV) is responsible for about 17,000 cancers a year in women and about 9,000 cancer per year in men.  About half of men and women in the US will be infected with HPV at some point in their life…around 79 million Americans.  Most of those infections occur between ages 19-24 and most of those young men and women will clear the infection on their own without a problem.  So, you might ask, why do we vaccinate against HPV?  Well, we know that almost 13,000 women in the US will be diagnosed with cervical cancer, and 99% or more of cervical cancer is caused by one of the high risk strains of HPV.  4,000 of those women will die of their disease.  Additionally, more than 200 million health care dollars will be spent in 1 year in the US to treat other HPV related diseases such as genital warts.  When you take into account all the screening for HPV related cancer and treatment of pre-cancerous HPV diseases the cost adds up to about 8 billion dollars.  That’s billion, with a B.  Imagine what our health care system could do with those dollars if we would significantly decrease or eliminate the burden of HPV disease through vaccination.

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The vaccine works.  Multiple studies have shown it to be extremely effective.  We’re talking 99% effective against the pre-cancerous changes that I see and treat on a weekly basis to try and prevent my patients from getting cervical cancer.  Right now about 39% of US adolescents are being vaccinated.  The goal is for 80% of those eligible to receive the full vaccine series.  In short, we are doing a terrible job folks.  In contrast, our friends in Australia have a vaccination rate around 75%.  They have virtually eliminated genital warts in those women under the age of 21 and soon will see a dramatic reduction in cervical cancer.

So why wouldn’t all our girls and boys age 11-12 receive the 3 dose HPV vaccine series?  Well,  first of all, our health care providers aren’t recommending the vaccine.  My friends from church have great trust in their pediatrician and have faithfully received all the vaccinations recommended to them.  But the HPV vaccine was not.  If we as health care providers would recommend HPV vaccination along with other routine immunizations for 11 and 12 year olds we could exceed the 80% immunization goal.  What are the barriers to provider recommendation?  Well, there could be several.

Our culture has made the HPV vaccination into a moral argument.  Parents believe that their child is more likely to become sexually active if vaccinated.  This has been proved incorrect in the medical literature over and over and over again.  Kids are no more likely to become sexually active after HPV immunization than they are to go seeking out someone to snuggle up with who has meningitis after being immunized against it at the same age.  We assume that people infected with HPV and those who have HPV related diseases must have done something wrong, behaved inappropriately, had “loose morals” or some other kind of disgusting label such as that.  The reality is that this disease can affect anyone.  Show me someone whose life turned out exactly as they had planned and whose children turned out exactly as they had planned and maybe you have an argument against vaccination…maybe.  But really for all of us, we don’t know what life will bring.  We can’t predict much of what will happen to us or those around us.  As I like to tell the medical students…no one leaves on a plane for  Africa to do some good missionary work with the intention of finding someone with yellow fever and being infected…but we still get immunized before the trip without question.  Immunization against HPV is just the same.

Additionally, our culture loves to believe what we read on the internet (ironically what you are doing right now).  Despite this vaccine being shown by research in the US and multiple studies in Europe to be safe and demonstrate no pattern of serious neurologic or other injury, many in the US are still afraid that HPV immunization will make your child sick or is some kind of conspiracy theory.  Does the vaccine hurt?…yes.  Are adolescents, especially girls, more likely to pass out with this immunization?…sure.  Do all immunization involve a very small likelihood of serious risk?…yes.  But that’s about it.  And those risks are much smaller than the risk you or your child has of being affected by HPV related disease.  Our role as health care providers is to educate and advocate.  If you ask any of my medical students they will tell you how they endured the “all things HPV” lecture during their time on OBGYN.  My hope is that there will be more voices who advocate for HPV immunization and than any loud voice that might tell them otherwise.

Screen Shot 2016-05-30 at 1.19.37 AMSo, health care providers….RECOMMEND the HPV vaccine.  Telling a women she has cervical cancer, treating recurrent genital warts, seeing complication of pregnancies caused by the treatment of HPV related diseases is heart-breaking work.  Trust that your patients will listen to you.  Present them with the truth and advocate for their future health and the health of the people they love.

Parents, pre-adolescents, teens, and those who know or love a parent, pre-adolescent or teen: don’t assume it can’t happen to you.  As Ben Franklin said “an ounce of prevention is worth a pound of cure.”  I hope I have to find something to do with those 20 hours a month I spend screening and treating HPV related disease.  I hope that someday we will speak of cervical cancer and other HPV related diseases like we do of polio.  Ask questions, get vaccinated, tell others.  If you have questions, ask a trusted health care provider.  If they can’t answer them, find another health care provider who can.  You never know who the 4000 lives are that would be saved.