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DR. SALGO: IT'S THE SECOND LEADING CAUSE OF CANCER DEATHS IN WOMEN WORLDWIDE. BUT WOULD YOU BE SURPRISED TO LEARN THAT THIS CANCER CAN BE CAUSED BY A VIRUS? AND HOW SURPRISED WOULD YOU BE TO LEARN THAT IT CAN BE PREVENTED? COMING UP ON SECOND OPINION.
MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION. THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE. WITH ADDITIONAL SUPPORT FROM THE FOLLOWING: THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.
DR. SALGO: WELCOME TO SECOND OPINION WHERE EACH WEEK WE SOLVE A REAL MEDICAL MYSTERY. WHEN WE CLOSE THIS CASE A HALF AN HOUR FROM NOW, YOU'LL NOT ONLY KNOW THE OUTCOME, YOU'LL BE BETTER ABLE TO BETTER TAKE CHARGE OF YOUR OWN HEALTH CARE. I'M YOUR HOST DR. PETER SALGO AND AS ALWAYS WE'VE ASSEMBLED A NATIONALLY RECOGNIZED HEALTH CARE TEAM. SOME ARE DOCTORS, SOME ARE NOT, BUT THEIR EXPERIENCE WILL HELP US TACKLE TODAY'S CASE. NOW, NO ONE, AS USUAL, ON THIS PANEL KNOWS THE CASE EXCEPT FOR ELISSA ORLANDO, OUR RESIDENT CIVILIAN. AND THIS WEEK'S PRIMARY CARE PHYSICIAN IS DR. LISA HARRIS. WHY DON'T WE GET RIGHT DOWN TO BUSINESS HERE? I WANT TO TELL YOU A LITTLE BIT ABOUT ELLEN. ELLEN IS A 46-YEAR-OLD ATTORNEY AND SHE'S BEEN MARRIED FOR 19 YEARS. SHE HAS TWO TEENAGED CHILDREN. ELLEN'S HUSBAND ROB IS ALSO A LAWYER. SHE'S CONSISTENTLY JUGGLING CAREER AND FAMILY, RARELY HAS TIME FOR HERSELF. HOWEVER, SHE ALWAYS TRIES TO MAKE TIME TO SEE HER GYNECOLOGIST ON A REGULAR BASIS. SHE GOES TO SEE HER DOCTOR FOR HER YEARLY PELVIC EXAM AND HER PAP SMEAR. THE PELVIC EXAM IS FINE. TOM DR. COX, WHAT THE HECK IS A PAP SMEAR?
DR. COX: A PAP SMEAR IS COLLECTING THE CELLS FROM THE CERVIX TO BE LOOKED AT UNDER A MICROSCOPE AND THE PATHOLOGIST, WHICH DR. DR. STOLER I'M SURE WILL DISCUSS THIS MORE, IS ACTUALLY LOOKING FOR CELL CHANGES THAT ARE DUE TO A SEXUALLY TRANSMITTED VIRUS CALLED HUMAN PAPILLOMA VIRUS.
DR. SALGO: I THOUGHT YOU WERE LOOKING FOR CANCER.
DR. COX: YOU ARE LOOKING FOR CELL CHANGES THAT ACTUALLY CAN LEAD TO CANCER.
ORLANDO: I KNOW THAT NO ONE'S EVER TOLD ME ABOUT WHAT A PAP SMEAR IS. I MEAN, WHEN PEOPLE DO MY PAP SMEAR AND I HAVE IT EVERY YEAR, IT JUST GOES AWAY IN A CONTAINER AND I HAVE NO IDEA I THINK THEY'RE LOOKING FOR CANCER EVERYWHERE...IN THE UTERUS.
BAZE: I DIDN'T EVEN KNOW THEY WERE LOOKING FOR CANCER.
ORLANDO: I KNEW IT WAS A CANCER TEST, BUT NOT JUST ON THE CERVIX.
DR. SALGO: WELL, HERE'S YOUR OPPORTUNITY, I'LL TELL YOU WHAT MARK DR. STOLER, YOU'VE BEEN LOOKING AT PAP SMEARS, YOU'RE A PATHOLOGIST, RIGHT?
DR. STOLER: RIGHT.
DR. SALGO: ARE ALL PAP SMEARS THE SAME?
DR. STOLER: NO.
DR. SALGO: WHAT'S THE DIFFERENCE?
DR. STOLER: THE BASIC PAP SMEAR'S UNCHANGED FOR THE LAST 40 YEARS, WHERE WE COLLECT THE CELLS ON A SLIDE USING A SPATULA-LIKE DEVICE OR A LITTLE BRUSH AND THE PHYSICIAN SMEARS THEM ON A SLIDE AND THEY GO IN A LITTLE BOTTLE OF ALCOHOL AND GOES OFF TO THE LAB.
DR. SALGO: THAT'S YOUR BOTTLE
ORLANDO: THAT'S THE...YES IT GOES AWAY SOMEWHERE.
DR. STOLER: BUT NOW IN THE LAST, LET'S SAY THE LAST TEN YEARS, I MEAN, THERE HAVE BEEN CHANGES IN THE WAY PAP SMEARS ARE PREPARED THAT HAVE REALLY LED TO A LOT OF TECHNICAL IMPROVEMENTS IN THE QUALITY OF THE SLIDE THAT'S MADE, AS WELL AS SOME IMPROVEMENTS IN THE SENSITIVITY OF THE PAP SMEAR.
DR. SALGO: WELL LET ME TELL YOU WHAT HAPPENS TO OUR FRIEND ELLEN. ELLEN GETS THE RESULTS OF HER PAP SMEAR. THE REPORT SHOWS ASCUS. ASCUS. WHAT THE HECK IS THAT?
PANEL: DON'T ASK US.
DR. SALGO: DON'T ASK US!
DR. COX: IT'S ATYPICAL SQUAMOUS CELL.
DR. SALGO: OK.
DR. COX: AND THE U-S OR "US" IS OF UNDETERMINED SIGNIFICANCE, WHICH JUST MEANS IT'S A BORDERLINE GREY ZONE BETWEEN NORMAL AND ABNORMAL. THE CELLS DON'T LOOK TOTALLY ABNORMAL BUT THEY DON'T LOOK TOTALLY NORMAL SO YOU'RE IN THAT SORT OF GREY ZONE AND THERE ARE ABOUT 2.5 MILLION WOMEN THAT GET THIS PARTICULAR PAP TEST READING EVERY YEAR IN THE UNITED STATES.
1 IN 1,000 WILL HAVE CERVICAL CANCER ALREADY THAT HAVE THIS. YOU'LL HAVE PERHAPS A RATE, GENERALLY AN ASCUS OF 6% TO 11% HAVING A PRE-CANCER. SO THE MAJORITY OF WOMEN DON'T HAVE A SERIOUS LESION BUT HOW DO YOU SORT OUT IN THAT LARGE GROUP OF WOMEN THOSE THAT REALLY NEED FURTHER EVALUATION TO PICK UP THOSE THAT ARE AT RISK.
DR. SALGO: BY THE WAY, HOW MANY PEOPLE WITH ASCUS GET BETTER WITHOUT DOING ANYTHING? DOES IT JUST GO AWAY?
DR. STOLER: 75 PERCENT...THE MAJORITY...
DR. SALGO: 75 PERCENT?
DR. COX: ABOUT 80 PERCENT.
DR. STOLER: 80 PERCENT.
DR. SALGO: 80 PERCENT. BUT THIS IS A PERSON WE'RE TALKING ABOUT, WHO'S SITTING ON THE OTHER SIDE OF A TABLE FROM YOU WHO JUST HAD WHAT COULD BEST BE DESCRIBED--AND I'M SURE SHE'S GOING TO INTERPRET IT AS--AN ABNORMAL PAP SMEAR. IF IT WAS NORMAL YOU WOULD HAVE SAID "GO HOME".
BAZE: YES.
DR. SALGO: YOU HAD ONE OF THOSE.
BAZE: YES.
DR. SALGO: AFTER LOTS OF NORMALS, TELL US A LITTLE BIT MORE ABOUT THAT.
BAZE: I HAD NORMAL PAP SMEARS, AS I SAID, EVERY YEAR FROM 18 TO 30 AND THEN I HAD SOME BLEEDING AT ONE POINT. I WENT IN TO MY DOCTOR AND THEY WERE LIKE, "OH, DON'T WORRY ABOUT IT. WOMEN BLEED BETWEEN THEIR CYCLES." AND I WAS LIKE, "OH, OK." MY DOCTOR SAID NOT TO WORRY ABOUT IT. BUT THEN WHEN I WENT IN FOR MY ANNUAL PAP IT CAME BACK ABNORMAL. AND I WAS LIKE, "WOW, THAT'S KIND OF WEIRD, I'VE NEVER HAD AN ABNORMAL BEFORE."
DR. SALGO: AND THAT GOT YOUR ATTENTION?
BAZE: IT SURE DID.
DR. SALGO: LET ME TELL YOU WHAT HAPPENED TO ELLEN.
DR. STOLER: OK.
DR. SALGO: BECAUSE ELLEN WAS NOT REALLY CONCERNED. SHE MIGHT HAVE BEEN ONE OF THOSE FEW PEOPLE WHO GOT THE ASCUS AND SAID, "DON'T WORRY, I'M NOT GOING TO ASK YOU."
BAZE: OK.
DR. SALGO: BECAUSE SHE REMEMBERED THAT SHE HAD AN ATYPICAL PAP AFTER THE LAST BIRTH OF HER SON. AND AFTER THREE SUBSEQUENT PAPS FOLLOWING THAT BIRTH, IT DID WHAT YOU TOLD ME 75% OF PEOPLE DO, IT REVERTED. IT WENT BACK TO NORMAL AND SHE'S BEEN NORMAL EVER SINCE.
DR. STOLER: AT 49 TO HAVE HAD, YOU KNOW, LET'S SAY TEN YEARS OF NORMAL PAPS AND TO ALL OF A SUDDEN HAVE AN ABNORMAL ONE, EVEN IF IT'S THE EQUIVOCAL THING WE CALL ASCUS, MEANS IT NEEDS TO BE EVALUATED.
DR. SALGO: THERE'S A LOT OF JARGON HERE AND THERE'S BEEN A LOT OF STUFF COVERED. WAS THE JARGON CONFUSING TO YOU, BY THE WAY?
BAZE: OH, COMPLETELY.
BAZE: I MEAN, NOW I UNDERSTAND IT BUT IT'S...WHEN YOU'RE FIRST LEARNING AS A WOMAN, YOU KNOW, IT'S LIKE, "WHERE'S MY CERVIX, WHAT'S IT DOING? WHAT DO YOU MEAN THE CELL CHANGES? IT CAN COME IT CAN GO." BUT IT'S IMPORTANT THAT EVERY WOMAN KNOW, AND NOW I HAVE A MUCH BETTER UNDERSTANDING.
DR. SALGO: ALL RIGHT, IT'S KIND OF LATE TO GET THAT UNDERSTANDING. WE HOPE THAT WOMEN WOULD GET THAT BEFORE, WOULDN'T YOU?
BAZE: NO KIDDING. YES, ABSOLUTELY.
DR. SALGO: WELL YOU KNOW THE PURPOSE OF A PAP SMEAR IS TO SAMPLE THE SQUAMOUS CELLS OF THE CERVIX--THE CELLS ON THE CERVIX--LOOKING FOR ANY CHANGES THAT ARE AWAY FROM NORMAL. A PAP SMEAR IS THE MOST RELIABLE TEST TO DATE TO SCREEN FOR CERVICAL CANCER AND IT'S ALSO IMPORTANT TO REMEMBER THAT A PAP SMEAR IS NOT A TEST FOR OTHER KINDS OF CANCER SUCH AS CANCER OF THE OVARIES OR CANCER OF THE UTERUS. ALL RIGHT, LET ME TELL YOU A LITTLE BIT MORE. ELLEN'S DOCTOR WANTS A FOLLOW-UP APPOINTMENT AFTER THIS ASCUS THAT HE GOT. AND SHE AGREES TO GO BACK TWO WEEKS LATER FOR A MORE THOROUGH EXAM. WHAT'S GOING TO HAPPEN AT THAT MORE THOROUGH EXAM?
DR. COX: WELL IF HE'S HAVING HER GO BACK IN TWO WEEKS, HE OR SHE, MUST BE DOING A COLPOSCOPY BECAUSE THAT'S THE ONLY PROCEDURE THAT YOU WOULD DO AT TWO WEEKS.
DR. SALGO: WOULD YOU WANT SOME HISTORY FROM HER, OTHER THAN WHAT I'VE GIVEN YOU?
DR. HARRIS: YES, I WANT TO KNOW HAS SHE HAD ANY--SHE OR HER SPOUSE--HAVE HAD EXTRAMARITAL AFFAIRS, IF SHE'S HAD ANY VAGINAL DISCHARGE OR ANYTHING ELSE GOING ON.
DR. SALGO: WELL, I CAN TELL YOU SOME OF HER GYNECOLOGIC HISTORY IF YOU'D LIKE. SHE GOT HER FIRST PERIOD AT AGE 12, AND SHE'S HAD NORMAL PERIODS SINCE THEN. SHE'S BEEN ON BIRTH CONTROL PILLS FROM AGE 18 TO 28. SHE HAD A TUBAL LIGATION AFTER THE BIRTH OF HER SON. SHE SMOKES ABOUT A PACK OF FILTERED CIGARETTES AT DAY. SHE MADE A POINT TO MENTION THEY WERE FILTERED...FOR REASONS WHICH WILL BECOME AT BEST UNCLEAR. SHE'S PHYSICALLY ACTIVE. SHE HAD FOUR SEX PARTNERS IN COLLEGE AND ONLY HER HUSBAND SINCE SHE GOT MARRIED, AND HER HUSBAND HAS NEVER HAD ANY RECOGNIZED SKIN LESIONS AT ALL.
ORLANDO: WAIT, WHY ARE WE TALKING ABOUT EXTRAMARITAL AFFAIRS AND SEX PARTNERS WHEN WE'RE TALKING ABOUT CANCER?
DR. GIULIANO: THE FIRST CONTACT WITH PAPILLOMA VIRUS IS THROUGH SEXUAL CONTACT, SO THE QUESTION HAS ALWAYS BEEN, HOW LONG DOES A VIRUS STICK AROUND? IS IT A PARTNER YOU HAD WHEN YOU WERE IN COLLEGE, YOU'RE NOW MARRIED AND YOU HAVE A MONOGAMOUS RELATIONSHIP. IS THAT VIRUS THAT YOU FIRST ENCOUNTERED AS A YOUNG WOMAN THE SAME VIRUS THAT'S CAUSING THESE CELL CHANGES?
DR. SALGO: WELL LET ME STOP FOR JUST A SECOND, I MEAN, WHAT THE HECK IS A PAPILLOMA VIRUS? SOMEBODY BRING US UP TO SPEED.
DR. COX: HPV OR HUMAN PAPILLOMA VIRUS IS A VIRUS THAT MOST PEOPLE THINK ABOUT CAUSING WARTS--HAND WARTS, FEET WARTS, GENITAL WARTS--BUT THERE ARE MANY, MANY TYPES, MORE THAN 100 TYPES OF HPV, SOME OF WHICH ONLY INVOLVE THE GENITAL TRACT AND THERE ARE SOME OF THOSE THAT ONLY INVOLVE THE GENITAL TRACT LIKE CERVIX, VAGINA, VULVA, PENIS AND ANUS THAT CAN CAUSE CANCER IN ALL OF THOSE AREAS.
DR. SALGO: A LOT OF THIS IS BASED ON YOUR SPECIALTY, EPIDEMIOLOGY, WHAT WE KNOW ABOUT THIS RELATIONSHIP BETWEEN THIS VIRUS AND CANCER. WHERE DID ALL THIS STUFF COME FROM?
DR. GIULIANO: A GROUP OF DIFFERENT EPIDEMIOLOGISTS LITERALLY AROUND THE WORLD STARTED DOING A SERIES OF STUDIES AND SAID, "WELL, IF IT REALLY IS CANCER-CAUSING THEN WE SHOULD SEE THE VIRUS IN WOMEN WHO HAVE CANCER AND WE SHOULD SEE A LOT LESS OF THIS VIRUS IN WOMEN WHO DO NOT HAVE CANCER." AND SO WHAT WAS STARTED WERE A SERIES OF STUDIES IN VARIOUS DIFFERENT CONTINENTS AND LO AND BEHOLD AFTER PROBABLY 20 YEARS OF RESEARCH WE FOUND OUT THAT MY GOD, THERE IS A VERY STRONG ASSOCIATION BETWEEN HAVING THE PRESENCE OF THIS VIRUS AND HAVING CERVICAL CANCER.
DR. HARRIS: AND WE DO KNOW THAT ONCE YOU'VE HAD SEX YOU COME INTO CONTACT WITH THIS PARTICULAR VIRUS AND IT PUTS YOU AT RISK FOR CERVICAL CANCER.
DR. STOLER: SO ALL THOSE OTHER THINGS LIKE GONORRHEA GIVES YOU SYMPTOMS AND HERPES GIVES YOU SYMPTOMS, BUT HPV DOESN'T GIVE YOU SYMPTOMS...DOESN'T HURT, DOESN'T BURN, DOESN'T ITCH. ALL IT DOES IS CAUSE CELL CHANGES. THAT'S WHY YOU HAVE TO HAVE YOUR PAP SMEAR.
DR. GIULIANO: BUT NOT IN EVERYONE. AND THAT'S SOMETHING THAT WE NEED TO BE REALLY CLEAR ABOUT. SO IF WE LOOK AT YOUNG WOMEN WHO ARE IN COLLEGE, AROUND 30 PERCENT AT ANY ONE TIME THAT WE TEST THEM WILL HAVE PRESENCE OF PAPILLOMA VIRUS. HOW MANY OF THOSE WOMEN ARE ACTUALLY GOING TO EVER SEE A PAP SMEAR THAT'S ABNORMAL? A VERY SMALL MINORITY.
ORLANDO: IF I STAY A VIRGIN, I'M NEVER GOING TO GET CERVICAL CANCER?
DR. HARRIS: THE LIKELIHOOD OF YOU GETTING A CERVICAL CANCER FROM HPV BEING A VIRGIN IS EXTREMELY LOW. ALMOST ZERO.
DR. SALGO: LET ME SEE IF I HEAR YOU ALL CORRECTLY THAT OVERWHELMINGLY WITH STATISTICAL INACCURACY PUT ASIDE, HPV AND CERVICAL CANCER ARE KEEPING CLOSE COMPANY, THAT IF YOU DON'T HAVE HPV YOU WILL NOT GET CERVICAL CANCER WITH A FEW OUTLIERS. MORE TO THE POINT, YOU SAID THERE WERE 100--I HEARD SOMEBODY SAY OVER 100...
DR. STOLER: MORE THAN THAT.
DR. SALGO: ...VARIETIES OF HPV. BUT THEY ALL CAUSE CANCER?
DR. HARRIS: NO.
DR. STOLER: NO.
DR. SALGO: WHICH ONES DO?
DR. COX: WELL THE TWO MOST COMMON ARE HPV 16 AND 18. 16 CAUSES ABOUT 50% TO 60% OF CERVICAL CANCERS. THE TWO OF THEM TOGETHER CAUSE ABOUT 70% TO 75% OF CERVICAL CANCER SO THERE'S TWO REAL BAD ACTORS. AND THAT AGAIN GOES BACK TO THAT THING THAT'S SO IMPORTANT FOR THE VIEWERS TO REALIZE THAT THE LIFETIME RISK OF GETTING HPV FOR ANY OF US IS PROBABLY 70% TO 80% AND SO AND MOST OF THE TIME IT'S TRANSIENT, THAT IS THE IMMUNE SYSTEM RESPONDS AND IT GOES AWAY.
DR. SALGO: ELLEN LEAVES HER DOCTOR'S OFFICE LOADED WITH ALL KINDS OF INFORMATION AND SHE DOES SOME RESEARCH ON HER OWN. EVEN THOUGH SHE READS ALL THIS STUFF THAT YOU'RE TALKING ABOUT, ABOUT DON'T WORRY ABOUT IT THAT MUCH, THERE'S A LOT OF VIRUS OUT THERE, A LOT OF HPV OUT THERE, HERE SHE IS READING THAT A VIRUS WITH AN ABNORMAL PAP SMEAR MIGHT BE SETTING HER UP FOR CANCER. WHAT DO YOU THINK SHE DOES? SHE GOES BACK TO HER DOCTOR'S OFFICE AND DEMANDS THAT SHE BE TESTED FOR HPV. DOES THE TEST EXIST?
DR. STOLER: YES.
DR. SALGO: CAN SHE GET IT?
DR. STOLER: YES.
DR. SALGO: WHY DIDN'T HER DOCTOR DO IT IN THE FIRST PLACE, DO YOU THINK?
BAZE: AND WHY ISN'T EVERY WOMAN GETTING AN HPV TEST IF IT CAN TELL YOU WHETHER OR NOT YOU HAVE THE VIRUS AND WHETHER OR NOT YOU NEED TO BE MONITORED MORE CLOSELY?
DR. SALGO: WHY DON'T WE JUST TEST EVERY WOMAN FOR THE VIRUS AND GET IT OVER WITH?
BAZE: MAKES SENSE TO ME.
DR. GIULIANO: WE HAVE SO MANY WOMEN WHO HAVE PRESENCE OF THE PAPILLOMA VIRUS, IT'S NOT A REALLY GOOD PREDICTOR ON ITS OWN OF WHO'S ACTUALLY GOING TO DEVELOP CERVICAL CANCER.
DR. SALGO: ELLEN WENT FOR HER HPV TEST AND SHE WAS CALLED BACK BY HER DOCTOR. SHE WAS TOLD THE HPV IS POSITIVE AND ELLEN SAYS THE OBVIOUS QUESTION, "DO I HAVE CANCER?" DOES A POSITIVE HPV TEST, BY THE WAY, I CAN TELL YOU IT WAS HPV 16 WITH THIS SMEAR, THIS PAP TEST, DOES SHE HAVE CANCER?
DR. STOLER: AT 49 WITH AN ASCUS SMEAR AND AN HPV 16 POSITIVE TEST, THE PROBABILITY THAT SHE HAS SIGNIFICANT PRE-CANCER, I'D SAY IS ABOUT 25%.
DR. GIULIANO: I DO WANT TO GO BACK TO THIS IDEA OF HPV TESTING BECAUSE WHAT WE DIDN'T TALK ABOUT THAT'S AN IMPORTANT FACTOR AND MARK RAISED IS THE AGE.
DR. SALGO: OK.
DR. GIULIANO: WHY DON'T WE TEST WOMEN FOR HPV INSTEAD OF A PAP SMEAR IN GENERAL? BECAUSE IN YOUNG WOMEN IT WOULD NOT BE PREDICTIVE. NOW AS WE GET TO OLDER AGES, IT'S WOMEN WHO ARE IN THEIR 40'S AND 50'S WHO ACTUALLY HAVE CERVICAL CANCER. THAT'S THE AT RISK GROUP WHERE YOU SEE THE HIGHEST NUMBER OF CASES OF CERVIX CANCER. HPV TESTING IN THE OLDER AGES BECOMES A MORE RELEVANT TEST.
DR. SALGO: ALL RIGHT, LET ME STOP THIS JUST FOR A MINUTE. HPV IS A VIRUS THAT IS ASSOCIATED WITH CERVICAL CANCER. IF YOU DON'T HAVE HPV, STATISTICS ASIDE, YOU WILL NOT HAVE CERVICAL CANCER. EVEN IF YOU DO HAVE HPV, IT'S IMPORTANT TO KNOW WHAT KIND OF HPV YOU'VE GOT BECAUSE ONLY A FEW OF THE HPV'S CAUSE CANCER. MOST WOMEN WITH THE CANCER-ASSOCIATED HPV'S WILL NOT GET CERVICAL CANCER.
ORLANDO: CAN WE GO BACK THE SCREENING FOR A SECOND AND THE TESTING? I MEAN, I HAVE TO SAY I'M A PRETTY GOOD PATIENT, BUT I'VE MISSED A PAP SMEAR, YOU KNOW, I MISS THEM EVERY ONCE IN A WHILE. BUT IF I HAD A POSITIVE HPV SCREEN, I WOULD NEVER MISS THEM.
BAZE: ABSOLUTELY.
ORLANDO: I WOULD NEVER MISS THEM BECAUSE I WOULD KNOW THAT THERE'S SOMETHING IN ME THAT'S POSSIBLY PUTTING ME AT RISK AND I'D GO EVERY YEAR.
DR. HARRIS: BUT WHAT WE'RE TRYING TO POINT OUT TO YOU THAT THE HPV TEST IN AND OF ITSELF IS NOT SCREENING FOR CANCER. THAT'S THE POINT.
BAZE: IT'S JUST SCREENING FOR THE VIRUS?
DR. STOLER: SCREENING FOR THE VIRUS.
DR. COX: SCREENING FOR RISK.
DR. SALGO: WE NOW KNOW THAT ELLEN IS HPV 16 POSITIVE. YOU HEARD HER HISTORY. WHAT DO YOU WANT TO DO RIGHT NOW FOR ELLEN?
DR. COX: WELL IF SHE HASN'T ALREADY HAD A COLPOSCOPY SHE SHOULD HAVE A COLPOSCOPY.
DR. SALGO: A STILL SOFT VOICE TO MY LEFT WAS GOING, "COLPOSCOPY!" WHAT IS A COLPOSCOPY?
DR. COX: WELL A COLPOSCOPY IS ACTUALLY LOOKING AT THE CERVIX WITH A MICROSCOPE THAT'S MOUNTED ON A STAND OUTSIDE THE EXAM, OUTSIDE THE VAGINA, OUTSIDE THE SPECULUM. THE CLINICIAN WILL LOOK AT THE CERVIX WITH THIS MICROSCOPE ON A STAND, WILL APPLY SOME VINEGAR TO THE CERVIX WHICH CHANGES CELLS THAT ARE GROWING MORE RAPIDLY, MAKES THEM TURN REAL WHITE, HELPS IDENTIFY SOME BLOOD VESSEL CHANGES, ALL THESE KIND OF MARKERS THAT WE LOOK FOR, FOR EITHER PRE-CANCER OR CANCER. AND IF THERE IS AN AREA THAT LOOKS ABNORMAL, A SMALL TISSUE SAMPLE IS TAKEN FOR THE BIOPSY, OR ONE OR MORE, AND THIS IS CALLED A CERVICAL BIOPSY.
DR. SALGO: ALL RIGHT, LET ME TELL YOU WHAT HAPPENED WITH ELLEN HERE. SHE HAD COLPOSCOPY WHERE SOME ABNORMAL AREAS OF THE CERVIX WERE NOTED. WHAT DOES THAT MEAN? ARE YOU GOING TO GO RIGHT TO BIOPSY THEN, IF I HEARD YOU CORRECTLY?
DR. COX: ABSOLUTELY.
DR. SALGO: YOU HAD A COLPOSCOPY.
BAZE: SURE DID.
DR. SALGO: WHAT HAPPENED AT YOUR COLPOSCOPY?
BAZE: THEY IDENTIFIED THREE SPOTS ON MY CERVIX THAT LOOKED KIND OF SUSPICIOUS AND SO HE TOOK THREE DIFFERENT BIOPSIES FROM THE THREE DIFFERENT AREAS AND THEN SENT THEM OFF AND HE SAID, "YOU KNOW, CHRISTINE, I THINK, YOU KNOW, WE'VE GOT SOMETHING GOING ON HERE AND YOU'LL PROBABLY NEED TO GET THESE CELLS SCRAPED OFF WITH A MINOR SURGICAL PROCEDURE CALLED A LEEP. HERE'S SOME INFORMATION, WE'LL MEET IN A WEEK AND WE'LL MAKE A PLAN." THAT'S HOW HE DID THAT.
DR. SALGO: WHAT DID YOU THINK AFTER ALL THAT?
BAZE: I WALKED OUT OF THE OFFICE SORT OF IN SHOCK BECAUSE AGAIN I WASN'T FAMILIAR WITH THE HPV VIRUS OR, YOU KNOW, EXACTLY WHAT WAS GOING ON IN THE PAP SO WHEN HE SAID, "WELL THIS CAN..." WELL I SAID, "WHY ARE YOU DOING THIS?" AND HE SAID, "WELL BECAUSE THERE'S A POTENTIAL IF YOU WALKED OUT OF MY OFFICE AND YOU DIDN'T COME BACK FOR FIVE YEARS, YOU COULD DEVELOP CERVICAL CANCER."
DR. SALGO: WELL ELLEN'S DOCTOR, HE WANTS HER TO COME BACK IN AND HE WANTS HER TO HAVE A CONE BIOPSY. WHAT'S A CONE BIOPSY?
DR. STOLER: A CONE BIOPSY IS A BIGGER BIOPSY.
DR. SALGO: SO IT'S MORE?
DR. STOLER: CERVICAL BIOPSIES, YOU KNOW, THEY'RE TAKING OFF LITTLE THREE MILLIMETER PIECES OF TISSUE AND SENDING IT TO THE PATHOLOGIST WHO, LIKE ON THE PAP SMEAR, THEY LOOK THROUGH THE MICROSCOPE AND ARE LOOKING AT THE WHOLE TISSUE RATHER THAN SCRAPED-OFF CELLS TO MAKE A DIAGNOSIS.
DR. SALGO: DOES IT FIND CANCER, PRE-CANCER? WHAT'S THE DIFFERENCE?
DR. STOLER: IT FINDS CANCER OR PRE-CANCER DEPENDING UPON WHAT'S THERE WHERE THEY BIOPSY.
DR. SALGO: WOULD YOU LIKE TO KNOW WHAT THE RESULTS OF THE CONE BIOPSY WERE?
BAZE: YES.
DR. SALGO: OK. ELLEN HAD HER CONE BIOPSY, WHICH CONFIRMED THE PRESENCE OF CARCINOMA INSITU WITH CLEAR MARGINS. ANOTHER COMPLEX TECHNICAL PHRASE. WHAT DOES ALL THIS MEAN, OH PATHOLOGIST?
DR. STOLER: WELL CARCINOMA INSITU MEANS THAT THE CELLS LINING THE CERVIX HAVE ALL THE CHANGES OF CANCER EXCEPT ONE REAL IMPORTANT ONE.
DR. SALGO: WHAT'S THAT?
DR. STOLER: GENERICALLY CANCER MEANS A GROWTH OR A PROLIFERATION OF CELLS WHERE THE CELLS ARE GROWING WHERE THEY DON'T BELONG. THEY INVADE INTO THE ADJACENT TISSUE. SO CARCINOMA INSITU MEANS THE CELLS LOOK LIKE CANCER, BUT THEY HAVEN'T INVADED YET.
DR. SALGO: DOES THIS MEAN, AND I'M SURE THAT THIS IS WHERE ELLEN'S MIND IS RIGHT NOW, DOES ELLEN HAVE CANCER?
DR. COX: THIS IS A SCARY WORD, CARCINOMA INSITU. CARCINOMA...
ORLANDO: THAT MEANS CANCER TO ME.
DR. SALGO: YOU'RE THROWING PHRASES AROUND LEFT AND RIGHT.
DR. COX: AND WHO KNOWS WHAT INSITU MEANS, RIGHT?
BAZE: RIGHT.
DR. COX: INSITU MEANS...INSITU MEANS "IN PLACE." IT MEANS IT ACTUALLY HASN'T INVADED. IT IS NOT CANCER. IT HAS THE POTENTIAL OF GOING TO IT IF IT'S NOT TREATED. BUT IT SHOULD HAVE 100% CURE IF IT'S TREATED APPROPRIATELY.
DR. STOLER: WELL CLEAR MARGINS MEANS THAT THE PATHOLOGIST HAS LOOKED AT THE SURROUNDING TISSUE AND IT MEANS THERE'S NO CARCINOMA INSITU OR NO CANCER-LIKE CELLS ON ANY PART OF THE EDGE OF THE SPECIMEN WHICH MEANS IF IT'S COMPLETELY EXCISED, YOU'RE BASICALLY CURED.
ORLANDO: SO IT CAME OUT WITH THE CONE BIOPSY YOU MEAN?
DR. STOLER: THAT'S RIGHT.
DR. COX: YES.
DR. SALGO: HER DOCTOR TELLS HER SHE HAD, DOESN'T HAVE, HAD CANCER.
DR. COX: I HEAR THAT A LOT...
BAZE: I'VE HEARD THAT, TOO.
DR. COX: AND THAT REALLY, REALLY BOTHERS ME. BECAUSE YOU HAVE TO GET THE TERMINOLOGY RIGHT IF YOU'RE A CLINICIAN. YOU'VE GOT TO NOT OVER-FRIGHTEN PEOPLE. THIS IS NOT CANCER. THE DEFINITION OF CANCER IS IT HAS TO INVADE BELOW THE SURFACE LAYER OF CELLS.
BAZE: SO INSITU MEANS IT'S STILL ON THE SURFACE.
DR. COX: INSITU MEANS IT'S ON THE SURFACE.
DR. SALGO: AND YOU'RE SITTING ACROSS FROM A DOC AS YOU DID. WHAT ARE YOU HEARING?
BAZE: I'M HEARING CANCER.
DR. SALGO: THAT'S WHAT I THOUGHT.
BAZE: THAT'S ALL I'M HEARING.
DR. SALGO: AND WHAT ELSE HAPPENS TO YOU? WHAT'S THE RESPONSE?
BAZE: FEAR, ANXIETY, MY GOODNESS WHAT CAN WE DO? TELL ME MORE. WHAT CAN I DO? WHAT CAN YOU DO? WHAT SHOULD WE DO?
ORLANDO: CHRISTINE, HOW DID YOUR DOCTOR TELL YOU? DO YOU REMEMBER WHAT THE WORDS WERE?
DR. SALGO: TELL US WHAT IT WAS LIKE.
BAZE: WELL, FOR ME, ONCE I HAD THE COLPOSCOPY AND THE BIOPSIES DONE WHAT HAPPENED WAS WE MADE THAT FOLLOW-UP APPOINTMENT FOR A WEEK LATER AND THEN I GOT A PHONE CALL ACTUALLY AT 8 O'CLOCK IN THE MORNING. AND I'M A MUSICIAN SO NOBODY CALLS ME AT 8 O'CLOCK ON THE MORNING! I WAS LIKE, "WELL, THIS IS WEIRD." AND THEY WERE CONFIRMING A DOCTOR'S APPOINTMENT WITH A DIFFERENT DOCTOR FOR LATER IN THAT DAY. AND I SAID, "WELL, THAT'S INTERESTING. I DON'T KNOW THAT DOC AND I HAVE AN APPOINTMENT WITH MY GYNECOLOGIST AT 11." AND THEY'RE LIKE, "WELL NO, YOU'RE GYNECOLOGIST SET THIS UP WITH THIS OTHER DOCTOR."
DR. HARRIS: THAT'S NOT GOOD.
BAZE: AND I WAS LIKE, "WELL, WHAT DO YOU MEAN AND WHO'S THIS OTHER DOCTOR AND WHERE ARE YOU CALLING FROM?" AND THE WOMAN ON THE PHONE SAID TO ME, "CHRISTINE, I'M SO SORRY. THIS DOCTOR IS A GYNECOLOGIC ONCOLOGIST AND I'M CALLING FROM THE NORTH SHORE CANCER CENTER."
DR. SALGO: LET ME TELL YOU WHAT HAPPENS TO ELLEN. SHE GOES HOME, HAVING ALL OF THIS. SHE ABSORBS ALL OF THIS. SHE TALKS ABOUT IT WITH HER FRIENDS AND HER FRIEND SAID, "I WATCHED TV THE OTHER DAY AND THEY TOLD ME THERE'S A VACCINE AGAINST HPV. AND I HEARD THAT SOME OF THE REALLY BAD HPV'S HAVE VACCINES. MAYBE YOUR NUMBER 16 HAS A VACCINE." AND ELLEN PICKS UP THE PHONE AND SHE SAID, "WHY DIDN'T YOU VACCINATE ME?" WHY DIDN'T THEY VACCINATE HER?
ORLANDO: WHAT DO YOU MEAN THERE'S VACCINE? FOR CANCER?
DR. SALGO: THERE'S SOMETHING IN THE PIPELINE, RIGHT? AN HPV VACCINE COMING UP.
DR. GIULIANO: THERE'S A PREVENTION VACCINE THAT'S ACTIVELY BEING TESTED INTERNATIONALLY TO SEE WHETHER THIS VACCINE, WHICH IS GOING TO CONFER PROTECTION AGAINST TWO OF THE WORST KINDS OF HPVS, 16 AND 18 THE MOST COMMON TYPES, ACTUALLY PREVENTS CERVICAL DYSPLASIA, OR THE PRE-CANCEROUS LESIONS.
DR. HARRIS: SO THAT MEANS YOU'RE GOING TO HAVE TO SHOOT FOLKS UP BEFORE THEY BECOME SEXUALLY ACTIVE.
DR. STOLER: THAT'S RIGHT. THAT'S RIGHT. BUT THOSE FOLKS...
DR. HARRIS: THAT'S YET ANOTHER SHOT FOR US PEDIATRICIANS TO GIVE.
ORLANDO: OK, SO DOES THAT MEAN--I JUST WANT TO GO BACK TO THE VIRGIN ANALOGY--IF YOU LINE UP ALL THE VIRGINS AND GIVE THEM AN HPV VACCINE THEN POSSIBLY YOU COULD ERADICATE CERVICAL CANCER?
DR. STOLER: THAT'S THE HOPE.
DR. GIULIANO: BUT REMEMBER THERE ARE AT LEAST 100 TYPES OUT THERE. WE CAN ARGUE WHETHER IT'S 13 OR 15 (TYPES) THAT ARE MOST IMPORTANT IN TERMS OF CANCER, CERVICAL CANCER. WE'RE TESTING THE VACCINE THAT HAS TWO ANTI-CANCER TYPES.
BAZE: SO THERE'S STILL OTHERS OUT THERE THAT THIS VACCINE WILL NOT PROTECT AGAINST WHICH IS WHY YOU STILL NEED TO HAVE AN HPV TEST?
DR. GIULIANO: CORRECT, AND ACTUALLY THAT'S A REALLY IMPORTANT POINT TO REMEMBER BECAUSE ALTHOUGH, LET'S SAY IN A FEW YEARS WE PROBABLY WILL HAVE A LICENSED VACCINE, I'M VERY OPTIMISTIC ABOUT THAT. THAT DOESN'T MEAN WE WANT TO STOP PAP SCREENING.
DR. SALGO: I WAS GOING TO ASK, IF YOU'RE VACCINATED AGAINST THE VIRUS AND YOU DON'T HAVE THE VIRUS BEFORE YOU START AND YOU NEED THE VIRUS TO GET CERVICAL CANCER, IF YOU GET THE VACCINE, WHY SHOULD YOU HAVE TO GET PAP SMEARS?
DR. HARRIS: LET'S GIVE ANOTHER ANALOGY. MANY OF US GET THE FLU SHOT EVERY YEAR. THE FLU VACCINE ONLY PROTECTS YOU AGAINST CERTAIN TYPES OF THE INFLUENZA VIRUS. YOU CAN STILL GET INFLUENZA IF YOU GET A DIFFERENT TYPE THAT'S THERE. AND EVERY YEAR WE MAKE UP ANOTHER VACCINE TO KIND OF COVER IT. SO YOU ARE GOING TO PROTECTION AGAINST THOSE TWO TYPES BUT YOU COULD POTENTIALLY, IT'S UNLIKELY BUT STILL POTENTIALLY, GET CERVICAL CANCER FROM A DIFFERENT TYPE SO YOU STILL NEED TO SCREEN, YOU STILL NEED TO BE VIGILANT.
DR. GIULIANO: ANOTHER REALLY IMPORTANT POINT IS THAT WE'RE GOING TO BE VACCINATING WOMEN PROPHYLACTICLY. SO WHAT DOES THAT MEAN? THESE ARE VERY YOUNG WOMEN, IT'LL BE TARGETED TO WOMEN BEFORE THEY INITIATE SEXUAL ACTIVITY. WHERE DOES THAT LEAVE ME, WHERE DOES THAT LEAVE YOU AND ALL THE OTHER WOMEN? WE HAVE AGE COHORTS OF WOMEN, DECADES OF WOMEN, WHO WILL NOT BE PROTECTED BY THIS VACCINE WHO CONTINUE TO NEED A PAP SMEAR.
DR. SALGO: LET ME STOP THIS RIGHT HERE FOR JUST A MOMENT BECAUSE I WANT TO SUM A FEW THINGS UP HERE. IT IS IMPORTANT TO CONTINUE TO REASSESS YOUR GYNECOLOGIC HEALTH EVEN IF YOU HAD A VACCINE, EVEN IF YOU'VE BEEN NORMAL IN THE PAST. WHEN VACCINES ARE MADE AVAILABLE FOR PREVENTION AND TREATMENT OF HPV, ANNUAL PHYSICAL EXAMS AND CYTOLOGY WILL REMAIN CRITICAL FOR WOMEN'S ONGOING HEALTHCARE. I THINK WE'VE REALLY NAILED THAT ONE DOWN. TELL US A LITTLE BIT MORE ABOUT YOU BEFORE WE LEAVE. WHAT EVER HAPPENED? YOU'RE HERE OBVIOUSLY, SO THINGS ARE GOOD.
BAZE: I'M HERE, SO THAT'S GOOD. I WAS DIAGNOSED WITH INVASIVE CERVICAL CANCER WITH EXTENSIVE LYMPHATIC INVASION. AND THIS IS AFTER YEARS AND YEARS AND YEARS OF NORMAL PAP SMEARS INCLUDING THE YEAR BEFORE SO THERE'S WHERE I GET ALL FUNKY ABOUT, "WELL, GOSH, THAT'S ASSUMING THAT THE PAP TEST WAS ACCURATE" AND THE PAP TESTS THAT I WAS GETTING CLEARLY WERE NOT ACCURATE ENOUGH BECAUSE I WAS THE GIRL WHO DID EVERYTHING RIGHT AND I STILL, YOU KNOW, NEXT THING YOU KNOW I WAS DIAGNOSED WITH THIS CANCER. SO 10 DAYS AFTER MY DIAGNOSIS, I HAD A RADICAL HYSTERECTOMY AND A MONTH AFTER THAT I HAD ANOTHER SURGERY TO MOVE MY OVARIES OUT OF THE WAY BECAUSE I KIND OF WANTED TO KEEP MY OVARIES FOR, YOU KNOW, HORMONES. I DIDN'T WANT TO GO INTO MENOPAUSE AT 31 AND, YOU KNOW, JUST KEEP THE CHANCE TO MAYBE HAVE A BIOLOGICAL KID. AND THEN I HAD FIVE WEEKS OF DAILY PELVIC RADIATION CONCURRENT WITH FOUR ROUNDS OF CHEMOTHERAPY AND THEN THAT WAS FOLLOWED BY THREE ROUNDS OF INTERNAL RADIATION.
DR. SALGO: YOU WENT THROUGH HELL.
DR. HARRIS: AND YOU LOOK PHENOMENAL.
BAZE: SO THEY GAVE ME EVERYTHING THEY HAD AND, YOU KNOW, IT WORKED AND I'M SUPER GRATEFUL FOR THAT.
ORLANDO: IN LIGHT OF HEARING THIS FROM YOU CHRISTINE, I HAVE TO ASK, I MEAN, ISN'T THIS ONE OF THOSE AREAS WHERE WOMEN, ESPECIALLY LIKE ME WHO JUST SORT OF HAVE THEIR PAP AND FORGET ABOUT IT, ISN'T THIS AN AREA WHERE WE COULD STAND TO BE A LITTLE BIT MORE INFORMED?
BAZE: ABSOLUTELY.
ORLANDO: WOULD IT BE SO BAD TO WALK IN AND SAY, "I WANT A LIQUID PAP AND I WANT AN HPV SCREEN"? WOULD IT BE SO AWFUL FOR ME TO WALK IN TO MY DOCTOR'S AND AT LEAST HAVE THE INFORMATION?
BAZE: YOU HAVE TO BE AN ADVOCATE FOR YOURSELF. YOU HAVE TO BE EMPOWERED AS A WOMAN TO GO IN AND BE EDUCATED ABOUT WHAT IS AVAILABLE, WHAT IS HAPPENING AND GO, HEY, I WANT TO HAVE A CONVERSATION WITH MY DOCTOR. I WANT TO KNOW WHAT KIND OF PAP TEST ARE YOU USING. I WANT TO KNOW, AM I ELIGIBLE FOR THAT HPV TEST? WOULD THAT HELP? I REALLY WANT THAT AND I WANT TO KNOW WHAT'S HAPPENING TO MY BODY. I DON'T WANT TO BE MISINFORMED.
DR. SALGO: HOW ARE YOU FEELING NOW?
BAZE: I FEEL GREAT. I FEEL GREAT.
DR. SALGO: THAT'S TERRIFIC.
BAZE: I HAVE SOME SIDE EFFECTS FROM SOME OF THE TREATMENTS AND YOU KNOW THAT'S ONE OF THE DOWNSIDES TO TREATMENTS BUT I FEEL OVERALL JUST WONDERFUL AND HAPPY TO BE ALIVE.
DR. SALGO: WELL WE'RE THRILLED YOU'RE HERE. THANK YOU SO MUCH FOR COMING.
BAZE: THANKS FOR HAVING ME.
DR. SALGO: I WANT TO THANK ALL OF YOU, TOO. JUST A TREMENDOUS DISCUSSION. BUT WE COVERED A LOT OF GROUND TODAY SO I WANT TO SUM UP THE KEY THINGS TO REMEMBER. THE PURPOSE OF A PAP SMEAR IS TO SAMPLE THE SQUAMOUS CELLS OF THE CERVIX LOOKING FOR ANY CHANGES AWAY FROM NORMAL. A PAP SMEAR IS THE MOST RELIABLE TEST TO DATE TO SCREEN FOR CERVICAL CANCER. IT'S ALSO IMPORTANT TO REMEMBER THAT A PAP SMEAR IS NOT A TEST FOR OTHER KINDS OF CANCER SUCH AS CANCER OF THE OVARY OR CANCER OF THE UTERUS. HPV IS A VIRUS THAT IS ASSOCIATED WITH CERVICAL CANCER. IF YOU DON'T HAVE HPV, YOU BASICALLY AREN'T GOING TO GET CERVICAL CANCER. AND NOW EVEN IF YOU DO HAVE HPV IT'S IMPORTANT TO KNOW WHAT KIND YOU HAVE BECAUSE ONLY A FEW OF THE HPV'S ARE BAD ACTORS AND CAUSE CANCER. AND AGAIN, ANOTHER IMPORTANT POINT, MOST WOMEN WITH THE CANCER-ASSOCIATED HPV'S WILL NOT GET CERVICAL CANCER. IT'S IMPORTANT TO CONTINUE TO REASSESS YOUR G-Y-N HEALTH, EVEN WHEN THE VACCINES ARE MADE AVAILABLE. FOR PREVENTION AND TREATMENT OF HPV, ANNUAL PHYSICAL EXAMS AND CYTOLOGY WILL REMAIN CRITICAL FOR A WOMAN'S ONGOING HEALTH CARE. AND OUR FINAL MESSAGE IS THIS: TAKING CHARGE OF YOUR HEALTH MEANS BEING INFORMED, HAVING QUALITY COMMUNICATION WITH YOUR DOCTOR. I'M DR. PETER SALGO AND I'LL SEE YOU NEXT TIME FOR ANOTHER SECOND OPINION.
SEARCH FOR HEALTH INFORMATION AND LEARN MORE ABOUT DOCTOR/PATIENT COMMUNICATION ON THE SECOND OPINION WEB SITE. THE ADDRESS IS PBS.ORG.
MAJOR FUNDING FOR SECOND OPINION IS PROVIDED BY THE GUIDANT FOUNDATION. THROUGH PHILANTHROPIC PARTNERSHIPS, THE GUIDANT FOUNDATION IS COMMITTED TO INCREASING PATIENT AWARENESS AND ACCESS TO ADVANCEMENTS IN CARDIOVASCULAR CARE, WITH ADDITIONAL SUPPORT FROM THE FOLLOWING: THE JOSIAH MACY JR. FOUNDATION AND THE PARK FOUNDATION.
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