The ABC’s of an abnormal PAP
By Lisa B. Samalonis

Reprinted Courtesy of Women's Health and Fitness Magazine, January 2005

Does it automatically mean cervical cancer?
What you should know about prevention, early detection and false alarms.

If you get a call from your gynecologist’s office about an abnormal Pap smear, don’t freak out. While even the words “abnormal Pap” can be scary, they can result for a variety of reasons. In many cases of cervical cancer, it can be detected early and treated fully. Each year, cervical cancer affects approximately 10,520 women a year, according to the American Cancer Society.

Routine annual gynecologic examinations are the first line of defense, says Ginger J. Gardner, MD, assistant professor, gynecologic oncology, at Johns Hopkins Hospital. Cervical cancer is categorized as early and late stage. “For early stage disease, typically the tumors are smaller and have a better response to therapy,” she says.

What you should know
Many times cervical cancer is undetected by the patient and the annual exam’s routine Pap smear can pick it up when only a small volume of disease exists. “Even prior to an invasive cancer, the preinvasive lesions can be identified by a Pap smear and they can be treated before it even gets to an invasive cancer.” she says.

After an abnormal PAP, most gynecologists recommend in-office colposcopy and biopsy. “This allows the clinicians to take a microscopic examination of the cervix and perform direct biopsies to an area that looks abnormal,” she says, noting that treatment options then are based on biopsy results. “If you get a call about an abnormal Pap it’s important to follow up, but don’t be too alarmed. It’s preliminary screen and there are a lot of things that can cause an abnormal Pap. That’s why the colposcopy and biopsy are so important. Make sure you follow up and don’t be scared off by fear of bad news,” she says.

If your doctor does not recommend colposcopy with biopsy after an abnormal PAP, ask why this step is not being done.

Treatment Options
For patients with preinvasive disease, also called dysplasia, close follow-up is recommended. ”Most low-grade dysplasia spontaneously resolves. Patients with low-grade dysplasia can generally be followed with repeat PAP smears and colposcopy,” Dr. Gardner says. “High-grade dysplasia are the concerning cell type because those demonstrate an approximately 15 percent rate of progression to an invasive cancer.”

Generally, high-grade dysplasia are excised, using either a LEEP procedure, or a cone biopsy, in an effort to remove the involved area before it progresses into a cancer, she says.

If cancer is detected on the biopsy or from the excision procedure, the patient is then referred to a gynecologic onocologist, who determines the appropriate treatment.

Conservative surgical approaches for young women diagnosed with cervical cancer are available. “A portion of cervical cancers are highly treatable, while other more advanced cases are less common. Early and small dysplasia can be conservatively ressected (removed). This is a big issue for some patients who want to preserve reproductive function or at least hormonal function and unfortunately find that they have a diagnosis of cervical cancer at a young age,” Dr. Gardner explains.

The link of HPV
A new HPV test checks for the sexually transmitted human papillomavirus virus that is linked to cervical cancer. At least 60 percent of sexually active women under 35 are estimated to have had some kind of exposure to HPV.

There are several high-risk subtypes of HPV that are more closely correlated to developing cervical dysplasia and cervical cancer. “Many people can carry HPV and not necessarily be symptomatic that is why Pap screening is so important for women over 35,” Dr. Gardner explains.

Many doctors now offer two tests, a Pap smear and a HPV test. Some insurance companies, such as Kaiser Permanente, are recommending women get HPV and Pap screening every three years instead of every year in some regions of the country.

In a pilot program, Kaiser has separated the Pap test from the routine checkup. “For woman who are positive for HPV but still have normal Pap smear, we are asking them to get a Pap every year because we recognize that they are risk to developing abnormal Pap. For women who are HPV negative, we feel quite confident that they are safe and it is preferable for them to wait three years for their next Pap and HPV test,” notes Ruth Shaber, M.D., director of women’s health services for Kaiser Permanente's Northern California region.

Be sure to ask your doctor and insurance company about which tests are done or covered, how often, and why. “By learning their HPV status, women can know whether or not they are at risk,” says Christine Baze, musician, and cervical cancer survivor. “If you know you have HPV, you can take steps to proactively deal with the virus (such as stop smoking, stop taking the birth control pill, go more frequently for exams) and catch the cells before they become invasive and lead to radical treatment,” she says.

Dr. Gardner points out that a woman should always make time for her annual gynecological examination. With information, regular examinations and screenings, women can prevent or reduce the chances of ever getting cervical cancer.

HEALTH HOUSECALL
Spreading the word

When musician Christine Baze found out she had cervical cancer, the music stopped. After radical surgery, radiation and chemotherapy for an invasive form of cervical cancer, she grew depressed and no longer performed. Then she decided to help empower women by organizing the annual Yellow Umbrella Tour in which musicians tour the United States performing and spreading the word about cervical cancer prevention.

“Cervical cancer is preventable,” says Baze.“Many women blow off their annual gynecologic exam year after year. But the fact is, this visit can save your life,” she explains.

Baze encourages women to know what tests they are being given because not every doctor uses the latest technologies, such as a liquid-based Pap test. She also recommends that women who have an abnormal Pap, or who are 30 years old or older, get the HPV test with the Pap test. Finally, she says do not be afraid to have a conversation with your doctor.“If something feels wrong or different in your body — be clear and proactive. No one cares more about your health than you, and no one knows your body better than you.Trust your instincts.”

For more information about the tour: www.yellowumbrellatour.com.