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Dr. Slomovitz: 
Hi. This is Dr. Brian Slomovitz, and this is CE on ReachMD. I'm here today with Michelle Flint and Casey Cosgrove.

For this episode, we've been talking about a lot cancer care. The best way to treat cancer, though, is to prevent cancer. And one of the most preventable cancers we have is cervical cancer.

Before we start on screening, I'm just going to say something that's definitely not controversial, the best way to prevent cancer is through vaccination, HPV vaccination. I think that we'll all agree here that giving the vaccine when it is appropriately labeled prior to – we say, prior to sexual debut, prior to the chance of getting HPV – is crucially important for the cervical cancer.

NP Michelle Flint:
We’re counseling parents as well that they need to be vaccinating their children long before sexual activity. Parents like to think that their kids will not be sexually active, so it just needs to be routine that they're getting vaccinated.

Dr. Cosgrove:
I think that your point of preventing cancer is the best way to cure cancer, and the HPV vaccine strategy, by far, is our best opportunity. So I think incorporating that as part of routine pediatric care and making it a standardized approach is probably one of our best strategies to really put this disease behind us.

Dr. Slomovitz:
Current recommendations to begin cervical cancer screening age of 21 and then every 3 years if you're doing Pap testing alone, or every 5 years if you're doing HPV testing alone, or combination HPV and Pap. And then follow them and handling the abnormal tests, identifying the high-risk patients and things like that.

Casey, let's start off with HPV testing, identifying high-risk, 16-18, we know they account for most of the cancers. Besides for being HPV positive or negative, let's take a deeper dive, what are some of the things that you're looking for in the high-risk and the testing that we're doing for that?

Dr. Cosgrove:
Yeah, I think the HPV testing has really been somewhat of a game changer for us. We know that almost every single cervical cancer has an HPV-associated diagnosis.

And so if you're HPV negative, you can feel very reassured that cervical cancer is unlikely to develop.

For those individuals that are HPV positive, I think it's important to recognize that many individuals will have an exposure sometime in their lifetime. And so having a positive test isn't something that's wild and crazy. It just means that we need to be keeping a little bit closer eye from the cervical perspective.

Our technology is also getting so much better now. We know that HPV 16 and 18 are the prime culprits in terms of causing cervical cancer, but there's a long list of other HPVs that are still higher risk; they have a lower chance of developing in the cancer.

And so making sure that we're taking the HPV strand that we're identifying, and tailoring our treatment planning or monitoring plan based off of what the risk that they might develop cancer is really critically important, because we know that all HPV strands are not created equal.

Dr. Slomovitz:
Great. Thank you for that. So when do you stop doing HPV testing for your patients? When do you stop doing cervical cancer screening for your patients?

Dr. Cosgrove:
Yeah, unfortunately, I'm starting to see more and more patients that are past the age of 65 with a cervical cancer diagnosis, and they haven't seen a gynecologist in years. So really, I kind of base the cervical cancer screening for my individuals after the age of 65 based off of their overall health, their desire for aggressive screening and treatment should we identify something. And also I stress the importance of having a routine gynecologic care.

Dr. Slomovitz:
And the other thing about stopping testing, a lot of my patients who've had a hysterectomy come in and say, ‘Well, I've had a hysterectomy, I don't need it anymore.’ If you have a hysterectomy with a history of normal Paps, and it wasn't done for cervical dysplasia or something like that, then that's not unreasonable. But a lot of times we're doing a hysterectomy for cervical dysplasia, CA-II or greater. Those patients, as we know, we have to worry about vaginal dysplasia, vaginal cancer, so they need screening.

Michelle, other end of the spectrum. You and I, we see a lot of younger patients who are at risk. Right now, the guidelines are saying that we don't need to start screening until the age of 21. What are some of your thoughts about that? And when would you start doing testing on otherwise healthy young woman who is sexually active?

NP Michelle Flint:
So we're coming from the standpoint of oncology. We work in gynecologic oncology, we see cervical cancer on a daily basis. So we are doing Pap tests on women who are under 21, especially if they have risk factors.

We know that their immune systems are likely robust, unless they're immunocompromised, and they will likely be able to rid themselves of the HPV virus, but we monitor them. We're not doing anything very invasive but making sure that we're keeping them safe and it's not developing into anything concerning for cancer.

Dr. Slomovitz:
Yeah, and I think it's spot on. I think real-world sense is important. And same thing in some of these younger patients, even with a negative HPV test, personally, I feel more comfortable bringing them in more frequently than every 5 years for a test. We're doing a lot that saves healthcare systems doing what's the cost-benefit. But I think, more importantly, when we identify high-risk patients, we need to keep a close eye on them.

I think, again, best way to cure cancer is to prevent cancer. Cervical cancer screening is something that we can't forget.

Michelle, Casey, that's the time we have. Thank you very much. 

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