[Music] thank you for taking time from your busy day to watch this special presentation from the El Paso County Medical Society I'm Dr Joel Hendricks president of the El Paso County Medical Society and it is my hope that you will find our program of great interest educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland from all of us at the El Paso County Medical Society please enjoy tonight's [Music] program how important is it to get regular cancer screenings in our community there are a significant number of cases of advanced cervical cancer this is likely due to a lack of proper screening in the past also limited access to health care services poor followup recent immigration status specifically here in our community and missed opportunities for vaccination and other preventative measures and where does HPV come in that's the human papala virus and that has gained a lot of media recognition over the last several years especially because of the vaccinations where does that fit into all of this our goal this evening is to educate the community and provide preventable measures and treatment options for women and today specifically discussing cervical cancer during the next hour we have experts answering questions about all kinds of female issues again oncology specifically with females and this is underwritten by Sparrow women's oncology center and a big thank you to the El Paso County Medical Society for bringing the show to you for over 26 years I'm Katherine Berg and this is the AL Paso physician thanks again for joining us today we're going to be talking about female oncology specifically cervical cancer and we have with us this evening Dr Travis Mendel who is a radiation oncologist and he's been on the show several times in the past and actually brought the show to us this evening so thank you so much for being here and we also have Kayla CA who is a nurse practitioner who works a lot with Dr mendal so Dr mendal uh true to form we were talking about this before we started for a radiation on colge ologist and specifically in this discipline what is it that you do all day and what is it that you're bringing to us this evening to discuss so as a radiation oncologist I guess first of all I work with a rran cancer specialist which is a subsidiary of uh rran neurology um but we treat uh solid tumors for the most part U with radiation it's typically external beam radiation um we have something called brachi therapy which is an internal type of radiation and then we also now have um what's called Diagnostics or radionucleide um radiation where we actually have injectables that Target cancer cells um but specifically for cervical cancer gynecologic millanes we're usually doing external beam treatments and bracki therapy for this okay so I see the patients typically after Kayla does um or the patient or if the patients also undergone surgery um we'll see them in clinic and then make recommendations on whether or not those patients need radiation um as an adant treatment option or even definitive with ch and just interviewing you over the last several years there are so many new things when it comes to radiation oncology I mean every time you come here it's like oh we're going to talk about this now but guess what's coming in six months and that's something I like to talk about too just in general what's always on the horizon it's always very exciting to to talk to you about that kind of stuff so oh sorry yeah go ahead please go in sorry so um so with cervical cancer you know really the the techniques haven't changed that much and we still do external being we follow add up with um usually with brachi therapy um the technique of the brachi therapy has changed and you know somewhat evolved over time um we're able to introduce catheters um interstitial needles into the tumor so that we can spread the dose out more laterally in the patient more to the sides um so that you can cover the entire tumor um and you know obviously do that safely while protecting the rectum and bladder um these organs that are important to the patients um when you're talking about this I'd like to you know what might stay in the body what duration of time is but anyway that's something we're going to talk about in a little while but I wanted to make sure that I say that out loud so you can remind me as this hour goes on absolutely um Kayla let's talk about you so nurse practitioner I feel like that's uh a title that covers so many different things but specifically with what we're speaking about tonight what is your scope of Duties so to speak so I'm a women's health and oncology nurse practitioner so I have have two Specialties and with these Specialties I have a practice which is called gynecologic oncology which is essentially uh treatment of female reproductive tract cancers okay okay this includes cancers of the cervix of the uterus of the Fallopian tubes the ovaries the outside of the um female parts which is called the vulva or the vagina as well those are all parts of the uh female anatomy that we that we treat in this specialty called gynecologic ology okay and so my typical day is involved with uh seeing patients who are either in the beginning of their treatment Journey which could include anything from surgery alone to um chemotherapy to radiation and immunotherapy is another um type of treatment that is um in the cervical cancer Arena and in the gynecologic cancer Arena and so I'm treating those patients I'm also seeing patients that have already completed their treatments and they're in what's called survey where we're monitoring them periodically to make sure that if their cancer does come back we C catch it at a very early time and are able to Institute therapies U quickly in order to help to retreat the cancer if it's needed and unfortunately I also do care for patients who are at the end of their life and who may not be um doing so well and may need to stop therapies at that point so from the very beginning to the very end um gynecologic oncologists and um which are the Physicians I work for and nurse practitioners like myself um we work in a multi-disciplinary team with radiation oncologist like Dr mendle um infusion nurses Hospital staff um staff in the clinic nurses these are all part of our what we call a multi-disciplinary or multiple people team um to take care of patients throughout their Journey okay um what are screening guidelines now what were they a couple of years ago what do you perceive them being and to your point that we talked about prior to the show they seem to be lightening up a little bit on screenings which I think is odd um I shouldn't say I think it's odd sometimes you think okay well if things are okay for a while the screenings have gotten so good that they were able to find something earlier than in times past and is that why and I'm just throwing that out there I know it's kind of a loaded question uh but we brought it up before the program so in general what are screening guidelines now for cervical cancer so is that for me or is that that's for Dr mendle or or unless you want to throw it to Dr to to Cayla we can do that too so kind of like I talked about before I feel like I have to look them up every time okay because it's all single time I you know I look at it and I'm like okay and then I almost always immediately forget it because I know I can I can look it up later okay but also when I look it up or if I try to remember it the next time I look at it it's slight different it's different so who's in charge of changing it so is it the American Cancer Society guidelines or uh National Cancer Institute how how does that work and who decides what the guidelines are going to be any any given year there there's there's actually different sets of guidelines depending on which um which group like Cooperative group you're going to follow okay um I don't know all their names to be honest but um but they they have their different screening guidelines I'm not sure which one um Kayla generally follows but so they you know you can go anywhere between you know the one that's probably the most conservative which is the um us preventative task force okay um and so that one um they have very their screenings they they're basing it on a population and they're looking at cost as well and whether and whether it's cost effective to screen so frequently so usually their recommendations are usually much more conservative and that's because they're probably more fiscally conservative okay um and then the um the ones that we usually follow are something called the asccp which is the American American Society for cervical path cervical Psy cytology and pathology and that's the one that we use for uh cervical cancer screenings there's also the American Cancer Society they have a set of guidelines too so just like he said there's multiple organizations that you can follow um there's other organizations like the American um College of Obstetrics and gynecologists they have their own screening their own type of guidelines as well so as a provider you really have to decide which one you want to follow um usually so it's not mandated on any specific no absolutely not it's not and so that's what kind of makes things a little bit confusing not just for patients but if you can imagine we confused sometimes too because they change like Dr mle says you has to look them up all the time and so do I yeah um and so and then once you start getting into where you have abnormal screenings then that's a whole another set of ways to manage things and so then you really are using a lot of the stuff that we use now is we use apps where we input what the patient's papsmear was what was their biopsy so on and so forth what's the next step and that kind of helped helps us um to to follow what kind of guidelines specifically so what what right now even off the top of your head if you don't know exactly without looking it up what are the screening guidelines now like what is the so right now I would say I following the ascp guidelines um that the screening guidelines are starting at age 21 okay um and not before women should start having psmears um with what we call so there's there when you do a papsmear there's different there's different things that's happening so whenever you go in for your papsmear mhm there you're not when you're going let's say this whenever you're going in for your wellwoman GYN exam okay and we want this to be once a year now stress that so no matter what the guidelines say this is always good to go once a year he talked about cytology he talked about other things too so let's make those specific and so that's one thing actually that as providers we need to do a much better job of educating our patients about the difference between a papsmear and a wellwoman exam so a wellwoman exam is when you're going in you're getting you know you're looked at from head to toe you're getting a breast exam you may or may not be getting Labs they're taking a look at all of your female parts so not just your cervix which is inside inside where they have to insert a speculum but they're also looking at the vulva which is the outside the vagina then they're going to do a b manual exam to fill your uterus and see if sometimes they may or may not fill your ovaries so whenever you have the actual P test is when they're putting in a speculum they're going in and they're using different things they can use a spatula with a brush or they can use something called a cervical broom and they go in and they're taking a sample of the cells that are Shed from the cervix right okay in addition to that you may also have an HPV or human papiloma virus test okay and so that's the difference there's there's two things that that may be happening at that time so whenever we the screening guidelines say from age 21 to age 24 you should be having just the cells taken not the HP PV test every 3 years okay that doesn't mean you don't see your gynecologist but every 3 years that just means that he's that the he or she is just doing the Pap test every three years but every year when you go in they are looking at the cervix and making sure they don't see anything abnormal that they may need to biopsy or do a work up on or do other things checking for um sexually transited infection so on and so forth or any other types of infections so then from ages 25 into age 65 then you would do either that cytology alone again that cells which is the papsmear Alone um every 3 years or you could have a papsmear with an HPV test which is preferred that is the pref that is the preferred method together I'm going to ask a quick question here is that something that the Patient Advocates for themselves like does a patient then ask on their own say Doc I would like to have both I would like to have the cytologist ol test which is a Pap smar and I also like to have the HPV test or is that what the doctor and or screener decides on their part so in my opinion the patient is in charge excellent that's why we're here this is all about the patient is in charge and we are here to help work to work with the patient and to guide the patient as to what the recommendations may be um however the patient is in charge but the preferred is that test the papsmear with the HPV test together every 5 years okay and so then um or it could be just the HPV test by itself with no sampling of cells alone every five years this does get confusing it's very this this is very complex it's very complex um so if a patient and I'm just trying to think of myself and and my daughter you know as she's growing into years and she's about to she's of child birthing years sorry anuka she's you know she's 26 but to me I I always look at these programs like what am I teaching my kids going forward and uh to your point every year honey you go in you you go get your girly checkup that's what we talk about um so on that note do I as a mom does the audience as parents and or people of within the ages of 25 to 60 do they then advocate well every 5 years I want this and that and the other do they know what they're asking for or do they like most women Frank L they'll go in every year and they just get whatever tests are given to them and then they go away and they wait till next year you know they usually say okay what time next year would like to come in and you you go again so it's almost like this rot thing that women do and Dr mendle you're you're kind of looking me with a a bit of a nod so I'm going to turn things over to you that's if they go that's that's if they go good point the big problem we have in our patient population is people a lot of our patients don't go to the doctor and if they do they wait forever so I have you know almost every patient I see for cervical cancer they're usually young like in their like young women in their 20s and 30s and I asked them I'm like you know how did this happen tell me you know some of them have been having these symptoms for over a year vaginal bleeding pain and they just didn't go they didn't have insurance they didn't know who they could go see they just didn't they you know they didn't have access so you're opening up beautiful cannab worms and I'm going to call it beautiful because I think this is a place where we can educate if people hav't tuning in if they're having symptoms you mention vaginal bleeding they you mention pain what other symptoms are there and where do they go if they don't have a doctor that they see regularly so that is a great question there's it's a terribly loaded question I'm sorry but it's super important for people to hear so you can I mean you you can think of um the symptoms progressing as the tumor obviously grows and gets worse so it starts in the cervix that's obviously in the pelvis um you know it's it's usually starts right at the O like it's the the opening into the uterus from the cervix that's usually where these start um and so it has direct access to the vagina so these tumors are usually Frable the blood vessels aren't formed well and so they bleed so bleeding is you know a very common uh symptom that the patients will have uh and I'm going to interrupt really quick as a patient how would you know if you're having your period or if you're bleeding abnormally is that associated with the pain and I'm just trying to think of what my daughter would ask me that is very common um like what the patients tell me they say I thought I was having my period it didn't go away or I just kept getting my period every like one or two weeks and it kept getting worse um and then you know sometimes they'll eventually go to see someone um but it's been going on for a long time and they just didn't have they didn't know where to go what to do um or they just thought that they didn't have insurance so they couldn't see anyone um but you know it's it's a it's a difficult situation when you're when you don't have insurance UMC has all kinds of programs um discount programs for patients that are uninsured um and so even you know at the least you can you show up to the ER right so if you're having vaginal bleeding and it's been persistent you're having pain problems urinating um you're someone's going to do a speculum exam right and they're going to find something and that'll at least get you plugged in um to some and this is something too and I and I do want to bring this up because I think when we talk about in general genitals right it's not something people want to talk about it's embarrassing who am I going to ask about this where what am I going to say once I get there I'm embarrassed about it uh if we could somehow it's so easy for us to sit here and talk about well the stigma don't be embarrassed go do it but what what is it that you relay to your patients when it comes to talking about stuff that they're not comfortable speaking about so I usually try to to make it make them feel comfortable with the situation and then I also try to help them realize that this is something we're doing all day every day so you're you know you're not the first person we're we're you know investigating these symptoms um so usually it's all about you know communicating with the patient what you're doing making them feel comfortable and you know helping them understand the importance of of these procedures um but kind of getting back to to you know the original conversation a lot of these if patients would you know get screened if they would get their vaccines that these these number one diseases are or at least cervical cancer itself is somewhat preventable or wholly preventable um but also you can catch it earlier right so you know there's a whole the staging process which we can go through but but really based off of you know how advanced the tumor is that leads down to what treatment options the patients have if you catch them early the treatments are not as in not as invasive as they are once they come to me or we're doing chemotherapy and radiation and all these um much more morbid um so I love that you're saying that this is preventable so let's now switch gears and really highlight the HPV vaccine um again 26y old and I say this because when she was young turning into an adolescent to a teenager this is something that her pediatrician now okay well now this is m not mandated but it's the recommendation now from the pediatrician office to get the HPV vaccines um I think there were two at the time so this is when I say new 20ish years which is still in my book kind of new how important is that and where do they get their vaccine is that you can only get through a pediatrician can you get that through clinics can you get that at a drugstore Etc so talk about that because we that's the push right of trying to get people to get their vaccines well I had my vaccines done it just one of the like County service um uh vaccine buildings okay I remember I I was in med school when you say that what does that mean County service so they have be there's mine mine was on off of Donathan I think they have different um like uh immunization centers um it's called immuniz El Paso right I was going to say how did you know to go there thank you very much IM we may even have a website for that I think it's called immuniz el paso.com called immuniz El Paso perfect okay honestly I don't even think because I was within I didn't pay anything I just showed up and got it um and I think it was a series of three injections um but I remember I was in med school when I got it and I I remember re learning about this and being like I need to get this right and so on that note too we talked a little bit about this when we were uh before we went on air you're a boy you're a guy you're a man you're a male uh if I say all the wrong words but in general again years ago it's like well that's something that the girls have to get and it's like wait a minute the boys have to get this too and you talked about two mouth and throat cancers you talked about all kinds of things so when was it that this wasn't just a vaccine that the females had to get this is also something the males had to get so I don't know when but the reason why is because the males are the ones spreading it right so we're the ones spreading it the females so you need to you know help stop the source and that'll help prevent um the spread of this this virus and there there's different um there's different types of the virus different like stereotypes or whatever they call it but um there's hundreds of them and there's high-risk versions and that's what the vaccines prot protect against um HPV 16 and 18 those are the the big ones for cervical cancer um and there's a couple other high risk types and that's why there's different vaccines now they had the bient now they had the qu they had the quadent I don't know if they have nonavalent nine nine now they have nine and it includes high-risk and lowrisk types so high-risk types are generally the types that cause cancer lowrisk types cause um genital warts okay so that's a that's a part of it too and so the nonavalent or um the G it's called gardisil 9 is um a vaccine that protects against both genital warts and again the lowris from the lowris types and then from cancer from the high-risk types forgot about the wordss yeah totally forgot about them oh trust me I can't forget about words think about it preventing a cancer but there's a lot of not everything but there's a lot of other things that it can prevent as well um on the guidelines of that what age if you have that off the top of your head what age do you start receiving the vaccine so you're looking at three different jobs at this point I I'm assuming that's still the case right well for children it's actually only two oh for the children children only get two from earlier children get two um I believe I can't remember the exact cut off age but I want to say 15 age 15 is a is a is the number that sticks in my head at that point um it's turns into three so at one point it does turn into three and the Hope here is the desire is before sexual activity correct the and that's the reason why they're V starting vaccination so young so anywhere between ages 9 and 11 is when that series is starting um and it just really depends so if you look at a vaccine schedule for the children it'll be they'll probably give it whenever they're going to need their next so you know booster or something the well child yeah so whenever like booster is then they'll probably give it with that okay yeah and so it's usually two I think another thing just to point out just for you know parents that it's so I can I can see the a scenario where a parent walks in their kids eight years old the the pediatrician is saying we need to give them their HPV vaccines you know my daughter son is not sexually active right right so so but they need to understand that it's it's going to protect them for the rest of their lives right exactly um or provide protection for them um not not not immediately but it will so um and I think that that leads kind of kind of back to the stigmas right the the parents are like no I don't want you know there's a big vaccine you know hunt nowaday back yeah but uh but I think that the parents just need to realize that this is not you know not not the the pediatrician isn't thinking that their eight-year-olds you know participating in these activities they're just trying to protect them for the rest of their life right this this hor like horrible disease and Kayla on that note since I feel like sometimes you're the the line that people see when there are parents who are um I don't know gunshy31 just you know assure them I mean because also in my you know I in my field I do birth control as well right and so you know a lot of times patients um you know parents think well if I put my kid on birth control it's going to make them more sexually active right and so sometimes you'll get that with the HPV vaccine if I give my child the HPV vaccine that's just giving them an invitation to be sexually active and so you know first of all just kind of squashing that stigma um and having that conversation and then telling them that you know cervical cancer is a horrible disease and it's preventable and if why would we not want to prevent a horrible disease that can possibly take their life or severely um affect their abilities to live a normal life uh have children um some of these women that we see are not even haven't even had children yet and they already have cervical cancer and so these are important things that I like to have you know I like to point out to them that this is what we're trying to to prevent here and thankfully since I work in an oncology office I'm able to tell my you know I sometimes I tell my patients who have had cervical cancer and they may have younger children please make sure exactly that you get your HPV vaccine because you don't want your daughter going through what you're going through um we want to prevent this from happening right so there's also that thought process too when you have a vacine it's against a virus and so this is a virus that can cause cancer so I think some people have have a hard time wrapping their head around that uh how is it that a virus is causing cancer is breast cancer caused by a virus is lung cancer caused by a virus you see where I'm kind of going with that right it's it's actually fascinating yeah and so that that's what I'd love to just bring up a little bit because I think that's the hurdle that people are are at least in my experience people are not understanding that how can a virus cause a cancer um and again maybe the narrative that you talk about when you said that's fascinating that it is a virus it causes a bunch of things it's not just cancer a bunch of you we talking about W you're talking about all kinds of things how do you wrap someone's head around that so uh actually was was thinking about this earlier um they have I I put a a diagram on that PowerPoint um I don't know if you all flip it up but um but basically the the virus when it infects the cell it's whole sole purpose is to hij hijack the cellular Machinery to make more virus right and you you have to do a couple things you have to stop the cell from dying you have to you know take over this the machinery for you know DNA and and construction of the actual like viral proteins um and HPV itself um uh manipulates two tumor suppressors one's called p-53 which is actually called the guardian of the genome and it is like it is the you know Mecca of of cancer genes um and it's you know when they they when I was taking courses in college on cancer this is like the first protein you study because it's supposed to be the guardian of the genome has its hands in all kinds of different cellular processes that protect the cell from becoming cancerous um so that's number one the virus attacks that yeah the virus the virus manipulates it it basically inactivates it so that the cell doesn't know something's wrong essentially nice um and then the other one is the retinoblastoma tumor suppressor as well okay so those are the two main proteins that it interacts with um but the the virus isn't trying to cause cancer it's just trying to make more virus right go which is why it's trying to live that's exactly gotcha um and so so but once it does manipulate these um these two tumor suppressors it makes the cell pre more predisposed to develop into a cancerous cell um and so that's why it's so important to stop the virus and prevent the the infections so I may be going down the rabbit hole a little bit on this but again virus right and this is let's say somebody gets the virus at the age of 17 can it stay dormant and is that even the right word to use for years and years on end when does it become active um and and again I don't know if that's that those are answers that you can answer or has that been studied quite yet so you have the virus you're sitting on it and all of a sudden at the age of 50 now we've got cervical cancer is it's something that could have been activating your body at the age of 17 18 19 in their 20s Etc how does that work or do we know we may not know um I think Kayla probably knows more about this but there are different flavors displasia and I know that when you um of course I've never had a pelvic exam I've done you know I've done many public they fun you should have one just for fun no just kidding not not that you can do that um yeah you know I know down somewhere else but Kayla let's let's attack that question um so so what happens is is that once the you get contact with the virus and so it's usually through SE it's through sexual contact that you get the virus the virus may or may not be active so just because you have the virus doesn't mean that it's active and so that's what makes it really tricky because you can have the virus in your body but the tests that we use is looking for active virus and it can be dormant so you can have a normal pops smar your whole life and never test positive for the virus but then it can be reactivated and the way that it's reative that it's activated is by by your immune system so if your immune system is lowered for whatever reason and one of the big things that likes to activate HPV is smoking so that is a huge risk factor for cervical cancer is smoking and so that's one of the first things that we tell our patients that may be smokers that have cervical cancer stop smoking interesting and so it can turn on and turn off I have patients that one year they're HPV positive next year they're negative then they're HPV positive next year they're negative often on off and on off and on when when it's inactive and it's dormant it's not doing anything it's not causing any problems but when it becomes active that's when it starts having problems so there are mechanisms in our body that can turn that turn that HPV off but when those me mechanisms fail for whatever reason and usually because of a lowered immune system then that's when it becomes active and then that's when it starts to attack however HPV is a slow growing virus so it has to be active for a prolonged period of time in order to actually start making changes and turn into cancer So when you say a prolonged period of time years years years I'm not talking mon when you said that Years Years not months so when patients tell me that when I see a patient with cervical cancer right they have had active virus for years goodness so and that's the reason why they have the extended intervals in the screening gotcha so remember your question about that and that the reason why is because it's very slow growing cancer so here's the question when you said a moment ago that one year you will test positive next year you'll test negative then positive then negative when someone tests positive for the HPV virus what are the actions to be taken next so usually the next thing that will happen is an exam called a coloscopy okay and what that is is that we're using a a microscope essentially to look at the cervix to see if we can visualize any lesions that the HPV is um causing so any changes we're looking for any changes that the HPV virus causes and the way that that actually happen that we can see it is we actually use vinegar you use vinegar for so many great things so we actually use it's acetic acid and we use vinegar and what we do is we put vinegar on the cervix and areas that are infected with the virus and that are starting to make changes they turn white huh and then we're able to visualize those those abnormal cells now these are before they ever even turn into cancer because the cancer doesn't turn usually doesn't turn white by that point if there's a cancer it's different it looks yellowish um in appearance it's easily easily bleeds if you touch it um but those what we call dysplasia which is just a fancy word for abnormal cells that's all that means so that dysplasia we're able to detect that before it ever turns into cancer and do things to get rid of it before it ever turns into cancer so I just had my colonoscopy yesterday a lot of this sounds similar to me in what is happening during a colonoscopy you go in you see a pup you remove it before it turns into a cancer so when you're talking about now you're going into the cervix you see lesions for the lack of a better word you see something that's suspicious that doesn't look good what do you do then do you physically remove them do you so you go in and actually scrape them out descri so first thing you're going to do is you're going to do biopsy mhm and then you'll send that off to the lab and you want to see what's the grade or how aggressive is this quote unquote dysplasia How likely is it going to turn into cancer so dysplasia is graded as mild moderate or severe or grade one two or three okay so mild dysplasia normally your body so women's women's bodies get rid of those abnormal cells on their own they shed those cells so that discharge that you have every month that normal every day that normal discharge those are your cells coming off okay your body can get rid of those mild changes on its own once does your body know to do that if it has yes it's very smart I mean aside from like on every everyday thing but if your body knows that there's something abnormal happening is that something that's in other words does your body know you have HPV does it know that you're positive and does it start shedding on its own it sheds it sheds those cells those cells are going to go come off on their own okay however if your body is not able to take care of it and that HPV infection so that's where that continued HPV infection if it's still present your body hasn't been able to turn that off and it's persistent and it keeps going and keeps going then those cells are going to keep changing and changing and changing until they finally turn into cancer but not all dysplasia turns into cancer because we have those mechanisms in our body that help to protect us and so once they get to a what we call intraepithelial neoplasia or dysplasia 2 or three at that point it's very unlikely that your body is going to be able to get rid of it on its own and so that's when we come in and we have interventions that we can do to help with that so describe an intervention describe what you are doing physiologically to the body to help get rid of these so we can do anything from what's called cryo oblas which is a freezing procedure where we actually freeze the cells and then they melt off we can use a laser where we go in and burn the cells and then then their body sheds them off or we can do an excisional procedure which is where we actually go in and physically remove tissue with either a knife in the operating room where we just kind of cut out in a little cone and get and remove the um the part of the cervix or we can use something called a leap which is a hot Loop that we use that we can kind of shave off that part the abnormal cells to get rid of them so that you're left kind of with a clean slate but then the body has to do its job and it has to fight the virus so that you don't continue to have the same process over and over again and that's where it's really important for us to be um doing the vaccinations because that does help us as well and it also so the vaccinations just to to to clarify is to prevent that neoplasia or abnormal cells two and three not one it's not going to prevent one okay it may or may not because one doesn't always turn into say I forgot what one is already so one is mild one is mild one is mild so mild moderate or severe right so the you still you still have mild hanging you can still have mild hanging out because mild usually your body takes care of it so it's not a big deal we're not worried about it it usually goes away rarely does it turn into the other part only when our body is not able to do what it needs to do so the vaccine is preventing against moderate severe and cancer okay that is the purpose of the vaccine so what ends up happening many times is I have patients coming in and saying but I got the vaccine so why am I here why do I have these abnormal cells and I have to remind them the purpose of your vaccine was to prevent you from having moderate severe and cancer that's what the purpose was not to prevent the mild cuz mild we can deal with mild no big deal our body can usually take care of it when you so I'm I'm going to go backwards here a little bit so when we're looking at again because I want to go back to treatment so we're looking about all the physiological things that you can do to the cervix itself to the lesions themselves to remove them I'm going to switch over to Dr mendle for a moment and talk about radiation so when and where I guess when in this process would radiation be now a resort to go to when it comes to cervical cancer so you we talked about in the opening that there are more cases of advanced cervical cancer and you're talking about 1 two and three that and that's not cancer yet it's just and that's not cancer yet so we're looking at this is still in the preventative stages correct and now we're migrating over to Dr mendal and now we're looking at some Advanced stages and then I want to if you don't and don't let me forget because you also said that followup after cervical cancer I do definitely want to talk about that to the surveillance afterwards but where does radiation come in with Advanced cervical cancer and and tell me how and how what options there are and how that's performed so so you can start I mean if if uh if you are able to throw up the slide that has all the stages and then treatment options for that that would be a great thing to show but basically you start you know from early stage cervical cancer it's usually a surgical disease um once it becomes invasive um to the point where we were're worried that the cancer is going to come back um that's when radiation comes in okay um and so it's usually there's different criteria um one's called s lless criteria this is after the patients had a hysterectomy okay and the cervix removed right so if the if the tumor is large greater than 4 centimeters if it's invasive usually more than a third um or if they have lymphovascular Invasion like it's starting to to go into the um lymph channels those are all risk factors for the tumor coming back and so we usually use those those risk factors to guide us whether or not the patients need radiation also patients can potentially need radiation after they have a hysterectomy and that's called the Peters criteria and it's oh yes I remember that okay and it's funny because it's a everyone in residency we have to remember these little acronyms and so it's p p p Peters um but it's positive margins parametrial Invasion so that's you know they remove so they for positive margins they obviously remove the tumor there's still some tumor left behind that's a positive margin um if it's perimetral Invasion that's the the tissue that's next to the cervix if the tumors is invading to there that usually requires chemor radiation adant um and then positive lymph nodes is another if they they'll usually do the hysterectomy they'll remove the ovaries and they'll also sample the lymph nodes um if the lymph noes come back positive that's an indication for adant chemo radiation okay and usually if the patient has a positive margin they'll get brachi therapy with an applicator called a cylinder now I'm going to stop for a moment too for those people who don't know what chemor radiation is describe that phenomenon because usually you have chemo or radiation and so right now you're combining these two words so describe what that means so so what we're doing is we're we're using the chemotherapy to enhance the effects of the radi of the radiation so patients will usually get radiation treatments daily um with these type of cancers and it's usually for five to six weeks okay they'll receive external me radiation to the pelvis and then the draining lymphatics as well once a week they will get chemotherapy and that basically sensitizes the tumor to the radiation and improves the patient's survival that's why we um give give the CH and radiation at the same time yes okay yeah and so of course it's more toxic right you have you know radiations pretty you know it's toxic it's not terrible the chemotherapy on top of it can make it a little bit more uh the effects more substantial um but you want that because you have more cancer and you want to kill the cancer so um but the patients they do well um you know of course there's a lot of coordination that goes on with with these and that's what makes these cancers so difficult because Kayla and I are always calling each other trying to figure out where you know where we're at with the patients and things like that because we work in different clinics um and the patients can be difficult sometimes um because they have their own lives and things going on and it's it's you know it's this massive effort to coordinate and get everyone like the whole team together to try to treat these patients and I think we do a pretty good job yeah seems like you guys got it together so here here's a question too we were talking about uh cervical cancer usually spreads the ovaries then we look at limb cells so it certain cancers spread to certain organs quicker than others and this one is natural you goes to the ovaries from there metastasis is always the word I'm thinking about um with cervical cancer Advanced cervical cancer where does it like to go once it spreads from the cice from the cervix so usually before you know before I do my treatments we almost always order a pet a pet scan okay talked about this the last program but there's a there's a type of pet called fdg pet which has been around around for a very long time yeah um and it's it's you know essentially indicated for a staging workup for cervical cancer it loves to go to the lymph nodes first okay it just loves the lymph nodes and it's it's um it's it's shocking how just the the pattern it follows it just kind of goes up the lymph channels and actually goes all the way into the left neck before it spreads into the body um sometimes it can go to like some lymph nodes you know and Escape into the circulation and usually once it's in the circulation it likes to go to the lungs so you're always looking you're always looking for the lymph notes you know like for me when I get my staging pet I'm always looking for the lymph notes because I can Target those and boost them with the radiation to make sure that I eradicate all the cancer cells within them okay um if I'm treating them definitively usually with chemo radiation right um and then when they if they have you know we've had a couple of patients that unfortunately have lones going all the way up to the diaphragm and also on the left neck and we'll treat everything and to try to eradicate it but the chance of cure in that case they're technically stage four um is is low but we give you know most of the patients are extremely young and we just give them you know give them a Best Shot yeah and this is a this is a young disease so that's something we should stress too um and I wish I had the graphic I'm I'm in my head looking at a graphic of the map if you will of the lymph nodes and I don't know if that's something you can kind of describe verbally for our audience but if you're looking at the lymph nodes of the body describe kind of where the lymph nodes hang out groin through up through the neck is there a so they they hang out by your artery okay that's a so so basically they start they they start on the pelvic sidewall essentially and then they go up to the aorta you have your your Commons and then they go to the aorta they go all the way up um your a aorta to essentially the the diaphragm um it can go in the media stum I've seen that a couple of times but usually once it's there it likes to go up up to your your super clave or super clavicular FASA um and so and then there it goes that's basically where the lymph lymph trans your circulation and then quickly to describe what the job of the lymph nodes are you know I always think to myself they're like they're filters they are for the lack of a better word it's a filter um and so I just like to have people think in their head why it would be important and dangerous for a cancer to get inside the lymph nodes because it is filtering well they're they're stopping the cancer from spreading so the cancer likes to go into the lymph channels you know there's not as much resistance in the lymph channel so it's pretty easy to get in there but the lymph nodes can capture them because they are filters and that patient always ask me I always use the filter every know my head too I'm thinking okay is there a better way to describe that but it makes sense and people can can actually see that in their head too um we're at about 15 you know 10 15 minute Mark of the show being finished so what I'd like to do Kayla if you don't mind um things that we have not spoken about yet this evening that in your head you thought you know what I want to make sure that I hit on ABC and D I know we've talked about a lot of the stuff that we've uh gone out to talk about but is there is there anything that we haven't spoken about yet or something that we have that you just really want to make a big point about before we start wrapping up so and then you know that question too I should have asked I should have asked Mr Mr Travis Dr Mendel about this first because he I have a couple if you want to you go first you have a couple cuz my biggest one is just the vaccination and getting your screenings right so in your head or maybe if you want to bring out your phone right now too we can give people places to call and or a website of where they can get their vaccination maybe you have that on top of your head and if so that's awesome so immunize El Paso okay your pediatri your children in their pediatrician's office many Primary Care doctor's offices also carry the HPV vaccine okay and you do not have to be a kid say if you're just hearing about it now and you're 35 you so you can get the HPV vaccination paid for by Insurance up to age 45 look at that but after age 45 it's usually going to be an out-of- pocket cost okay you can also get a prescription and get them done at um the pharmacy mhm that's an option as well and you can also um get them done at your OBGYN office and if you need a prescription I know there's a lot that you're going to have to talk about but still and we're going to talk about this again too if you need a prescription and you do not have a primary doctor you don't have a doctor usually go to where can you or how can you get a prescription the best place to go is is places like immuniz El Paso our County our County Immunization Clinics the main answer in general for that I would definitely recommend that gotcha Dr mendle I know you've got a lot of stuff so I mean I don't have a lot I just have a couple have a lot I love that about you I really do seriously but um just just to hit on the HPV um you know for cervical cancer it's it's like 99% of the time it is caused by by HPV it's like almost all the tumors are HPV positive um so that's why the vaccine is so important um for for men also there's been an an epidemic of throat cancer oringal canc over the last several years right and it's also another F fascinating like EP epidemiology epidemiologic um I love it you yeah epidemiological yes um but but essentially you know they uh I think it was back in 2010 or something like that they started to realize that the rates of throat cancer in males were Rising um and this was you know throat cancer in before you know in the early 2000s even before was mainly caused by smoking um and then once people realized smoking's bad for you they stopped and so those rates decreased but shockingly the rates of of these HPV positive oral Fingal cancers or throat cancers specifically in men started skyrocketing and they think that um or at least they started noticing that they were skyrocketing um and they think that women are are protected because they've already been exposed to the to the HPV early on in their life so they their body is already essentially inoculated for that virus but the men are not and so these cancers they they grow in the throat they're almost most of them are treated with um either surgery or radiation or chemo radiation as well so we do a lot of these these cancers in town as well um but uh but essentially it's you know the the vaccine will help prevent that as well um so that's another um just kind of fascinating side men and women women exactly yeah um and then another topic I wanted to talk about was was the def like treating cervical cancer definitively with chemo and radiation and the important Logistics you have to get through with that so like we like we said we were discussing before most of the patients they will get chemotherapy and radiation external beam UPF front but it's very very important that they get brachi therapy afterwards you know we kep mentioning it but we don't talk about it so describe bracky therapy so this is a this is a radiation treatment where we insert a applicator or we essentially construct an applicator inside the inside the vagina and a in a um a metal what's called a tandem that's basically like a metal catheter goes inside the cervix and then treats the tumor from the inside out with radiation M so the applicator in there and it's essentially a series of catheters and we hook that up to what's called an afterloader and an aridium Source comes out travels down a string into these uh into these catheters and emits radiation from its radioactive Source from the inside out and this and this stays in the body this is something that's it's in the it's in the patient for a couple of hours while we're doing the planning and the actual treatment just takes like 10 or 15 minutes oh it's very quick and then we take everything out um the issue here is the tumors are so Advanced that you can't just use it's it's like a miracle and I have a patient that I can just use a simple like Tandem and ring or Tandem and ovoid which are basic applicators that we use for these type of cancers here the tumors are are large they're invasive and so we're I'm always having to put interstitial needles in and so we have a set of catheters that have needle guides and we're able to extend the the these high doses out to the side like the the pelvic sidewalls almost um and it's funny because when when I was in residency these cases were rare like very very rare where you know maybe once a month or once every couple of months there would be a patient that would require this type of treatment and all the residents would you know go to the O and it wased you know everyone wanted to put the catheters in because it's it's you know it's it's sad but also it's it's you know exciting to do a surgical procedure and being in the o with the gyong of course um it's always you know G yeah so we you know it was always it was something new and different that we didn't get to see very often um mostly because you know it's in in in a lot of like in Dallas you know it's not as these Advanced disease are not as you know Common so here I see them every week every single week yes every week I like right now and I'm interrupting again sorry is that Al Pasa related is that this region related do you think or is it just a matter of knowing that this is just noticing that more of this is going on I I think that it's it's the location you think it's the location location patients aren't seeing their doctors they're not getting their vaccines and this is this is what happens and this is a disease that could you know potentially be preventable or much much easier to deal with but here it is hard and it is you know it's it's shocking like right now like every every almost every day I'm on the west side I'm doing these these type of procedures um for the patients in town and it requires anesthesia so we bring anesthesia to the office so the patients are comfortable and asleep um we have to coordinate with you know every all the other team they have to get their labs they have to stop their chemotherapy they all these all these things and it is it is a lot of work and so it's it's getting harder to find places that will do it because it's so it takes so much work and you know usually nowadays A lot of the in the community the hospital system will have a radiation department that that does this that will do take on these large procedures and so sometimes the patients can be go to Albuquerque or Dallas but that's another issue because a lot of these patients cannot travel so we we talked about at the beginning of the program so uh people who are tuning in just now they're like well why here what's the case why here why why is that an issue in our region I mean we just with the the procedural aspect well just the in general because we were lock we were talking about uh a significant number of advanced cases here in this region likely due to and this is part of the opening uh lack of proper screening limited access to health care services poor followup etc etc so is that something that that you and the team in this region has kind of seen those are all the issues that how can we help that you know again we're here right now so we're educating we're trying to get people to proper screenings to followup on on that note too before we wrap up um unless you have something else you want to add to that I do want to follow up on after someone who's been treated for cervical cancer you were talking about surveillance so that there are less chances for it to come back and if so that they know how to treat quickly I know we don't have a lot of time but I'd love for you to address that so essentially surveillance is just us you know looking for the signs and symptoms of the cancer returning and usually it includes anywhere um so most of these patients are going to get a pelvic exam usually in the very beginning they'll see us every 3 months okay and you'll get a pelvic exam where we're going to look at the areas that were that were affected sometimes it may include blood work that will give us an idea of whether or not the tumor may be returning and sometimes it will be Imaging with either pet scans or CT scans that will tell us um that the cancer may be coming back and might this be a lifetime going forward or is it like we look a lot for the next five years and then we kind of s down and then after five years we see them once a year but essentially most of the time we see these patients at least once a year for the rest of their life okay we turn into their gynecologist right and again quickly I know we talked about it too symptoms for people who are tuning in now what are some symptoms that can be mistaken for something else so just like Dr mendle said bleeding another big one is discharge abnormal discharge that does not does not responding to treatments um you know sometimes patients will have a discharge and they'll go and they'll do like a over-the-counter Monostat treatment or something and it doesn't work so if you're noticing that you're trying to deal with this discharge and it's not working you need to see your provider now this is a medical show so I'm going to ask specifically what kind of discharge are they looking for so usually they're looking for a foul smelling discharge um bloody um yellow to gray in color um that's and sometimes it's watery so if you're just looking for something that just does not fuel or or outside of your normal outside your nor most women know what their normal normal discharge is all women have discharge every day we have discharge when it starts to get weird that's when you need to say know your body and know when it is something's different now it's time to suck it up and go see the doctor I this show was absolutely fascinating thank you so much and thank you Dr men for bringing this to us Kayla you're an absolute Delight you're full of information and we she's aming right she's pretty did you tell did you tell the story of how we know each other yeah no I didn't I was I was thinking about bringing it up real quick we'll find that he was my medical assistant he was my medical student oh hello really he was my medical talk about a full circle moment yeah I kind of love everything about that and salivar was the first surgeon I met in medical school too that's the doctor I work for jeez so that's how we know each other gosh I want to say thank you so much to Sparrow woman's oncology who is bringing this to you and again any questions too I know there's websites the the search engines are great these days you can look up Sparrow women's oncology I want to say thank you very much to Dr Travis mendle who is a radiation oncologist slash all kinds of other knowledge that he's got inside of his head and then Kayla kasera who is a nurse practitioner but my Lord do you have all kinds of information um a big thank you to the El Paso County Medical Society again we've been doing this program for over 26 years and to watch this again you can do it at several different locations you can go to PBS ELP paso.

org and you can find the El Paso physician and then look at the show and then also epcms which is the El Paso County Medical Society site that's epcms dcom and you can also go to youtube.com and just enter the words the El Paso Phan and from there you'll have all kinds of topics that you can see topics that we've done in the past and if you have any questions you can always ask at those websites too thank you so much for watching I'm Katherine Berg and this has been the op Pasa Phan [Music] [Music] [Music] n