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19.01.2015

Treatment options for cervical cancer, cold sore on lip - Test Out

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In the low-resource countries of the world, 700 women die every day from cervical cancer, leaving behind families and communities that depended on them. Most cervical cancer in developing countries occurs in women who take care of children, provide income for families, and work in their communities. Poor women in industrialized countries have a higher incidence of cervical cancer than their wealthier neighbors.
Cervical cancer is caused by human papillomaviruses (HPV).6,7 Safe and effective vaccines have been developed against the HPV types responsible for most of the cancers.
These vaccines are now available for girls and young women; HPV vaccine has also been approved for boys in some countries (see information about vaccinating boys in the Vaccination strategies section below). Developing countries need strong and persistent advocates for cervical cancer screening and vaccination programs.
Human papillomaviruses comprise a large family of viruses, with more than 100 types known.17 Some types have a high potential for causing cancer (high-risk types), whereas others have a lower potential (low-risk types). While types 16 and 18 are the most common cancer-causing types worldwide, their prevalence varies slightly in different geographic areas. Normally, the surface layers of the cervix die and slough off, with a controlled stream of new cells constantly forming and pushing upward from below, in a manner similar to skin renewal.
Most women are infected with a high-risk type of HPV at some time in their lives, but, as mentioned above, only a small portion develop cancer.
For both men and women, the risk of contracting HPV infection is affected primarily by sexual activity; their own or that of their partners.
Being faithful to a partner and regularly using condoms are not sufficient precautions for significantly reducing rates of cervical cancer. Cervical cancer can be prevented either by avoiding HPV infection, or by periodic monitoring (screening) for infection and lesions. Avoid exposure to the virus through abstinence from sexual activity or through mutual monogamy forever, provided both partners are consistently monogamous and were not previously infected (but this is not considered practical for most people). The most familiar method of cervical cancer screening worldwide is the Pap test, but new alternatives have been shown to be as effective, or more effective, than Pap, often at a lower cost. Gardasil prevents infection with two of the most common cancer-causing types of HPV, types 16 and 18. Further, a booster shot of the HPV vaccine stimulated a response similar to vaccines that provide long-lasting protection, such as the hepatitis B vaccine.33 These findings suggest that the duration of effectiveness could be long lasting, but definitive data will become available only when clinical trial participants have been followed for a longer time.
In clinical trial reports for Gardasil,26 the most common side effect was discomfort at the injection site.
In the VAERS reporting system for tracking Gardasil, the most commonly reported adverse events following HPV immunization have been similar to those found in clinical trials: discomfort at the injection site, fainting, dizziness, nausea, and headache.
Programmes introduced to prevent cervical cancer should initially prioritize high coverage in the primary target population of young adolescent girls.
Once effective strategies have been developed to reach these girls, they can be used to provide additional health interventions appropriate for older children, such as other immunizations, deworming, malaria intermittent preventive treatment, provision of bed nets, nutritional supplementation, and general health and life skills education. Boys can become infected with HPV, they can infect female partners, and they can develop HPV-associated diseases such as penile, anal, and oral cancers or genital warts. A key goal for the future is to develop preventive vaccines that are more suitable to resource-limited areas. Currently, no therapies are available for active HPV infections, but researchers are working on vaccines that may prevent cancer in women who have persistent HPV infections. Cervical cancer screening of sexually active or formerly sexually active women can determine whether they are at risk of developing cervical cancer. Since its introduction more than 50 years ago, the Pap or cervical smear has been used throughout the world to identify precancerous lesions for treatment or follow-up.
A single cytologic screening results in a high rate of false-negatives—that is, it lacks sensitivity and cannot detect many cervical abnormalities, making repeat screening necessary. An additional advantage of VIA not offered by Pap or HPV DNA tests is that it allows providers to identify the small proportion of positive lesions that are unsuitable for treatment with cryotherapy, a mode of treatment appropriate for limited-resource settings (see Treatment of precancerous lesions below).


In addition to these tests, other molecular HPV tests are under development and are likely to be evaluated soon for clinical use. The success of VIA, HPV DNA testing, and cryotherapy in field settings signals new potential for cervical cancer control in places where cytology programs are not feasible or sustainable. Another concern for the future is what will happen when the current generation of newly vaccinated girls reaches the appropriate age for screening. In industrialized countries, women who test positive by either Pap smear or HPV DNA tests then undergo diagnostic testing, with colposcopy, for example.
Costs for delivering the HPV vaccine probably will be greater than those for existing infant vaccination programs. Accurate information is essential to improving understanding of both HPV and cervical cancer among health care workers, educators, policymakers, parents, and patients.
Because clinicians are often the primary source of information for both parents and adolescents, educating clinicians helps parents to understand the benefits of any vaccine.5,52 Health care workers in many developing countries might not have a clear understanding of HPV infection and its relationship to cervical cancer development and prevention. Cervical cancer is the second most common cancer in women worldwide and the leading cause of cancer deaths in women in developing countries. Among these are the hepatitis B and C viruses, which cause liver cancer, and the Epstein-Barr virus, which is responsible for several forms of lymphoma.
Most often, cervical cancer is found much later, usually after age 40 (Figure 2), with peak incidence around age 45 and peak mortality in the late 50s.
Both pre-cancer and cancer usually arise in the transformation zone, which is larger during puberty.3 In older women, the transformation zone is deeper inside the canal, and the epithelium is not as susceptible to infection.
Some lesions resolve spontaneously, but others can progress to invasive cervical cancer (Figure 4). Women can decrease their chances of developing cervical cancer by reducing some of the risk factors in the list above, but vaccination of adolescent girls against HPV and screening of adult women are the best ways of preventing this disease. Tests for HPV DNA have become available and may become a more common way of screening for infection. It is well-known from years of research that cancer is preceded by these precancerous lesions.
While the two vaccines cannot be compared directly because of differences in the way antibody levels are measured for the clinical trials, they both produce levels between 10 and 80 times that found in natural infections.
Data from randomized clinical trials are highly reliable, since reports of serious adverse events can be investigated and verified and there is a built-in control group for comparison.
Because of the reports of fainting, in June 2009, the US Food and Drug Administration required Merck to add a warning to the Gardasil package insert stating that individuals should be watched carefully for 15 minutes after vaccination to avoid potential injury from a fall.
In regard to serious side effects, these accounted for only 6% of all VAERS reports—and remember, these were not confirmed to be caused by the vaccine.
Forecasting and delivery strategies (in schools or community programs) can also be guided by this information.
In countries without screening programs, policymakers should consider initiating screening of women aged 30 and older once or twice in their lifetimes, in conjunction with vaccination of girls and young women who are not yet sexually active.15,40,41 To learn more, visit the Screening and treatment section. Routine use of Pap smear screening in the industrialized world has contributed to the 70% to 80% reduction of cervical cancer incidence in developed countries since the 1960s.48 Even in industrialized countries, however, the level of success can vary.
VIA involves washing the cervix with 3% to 5% acetic acid (vinegar) for one minute and observing the cervix with the naked eye afterward. A sample of cells is collected from the cervix or vagina using a small brush or swab, and the specimen is sent to a laboratory for processing.
This test is able to detect DNA from 14 cancer-causing types of HPV, with test results available in two to four hours. Single-visit approaches using VIA to screen can be offered now, and screen-and-treat approaches using HPV DNA tests for primary screening and VIA for triage may be possible in the near future in many low- to medium-resource settings. The vaccines protect against the two HPV types that cause 70% of cervical cancer, but not against those that cause the other 30%. Colposcopy is an examination of the vagina and cervix using a magnifying device with a powerful light source to identify abnormal areas on the cervix and to guide sampling of cervical tissue (biopsy).66 Colposcopy must be performed by trained providers, and colposcopes are expensive.


For advanced disease, radiotherapy (radiation) is frequently used to cure or ease symptoms, but in developing countries it is not widely available or accessible. Pain control for women with advanced cervical cancer is often inadequate in developing countries.
Many do not know the cause and burden of cervical cancer and may not be able to understand the value of HPV vaccines or cervical screening for improving the current situation. Effective framing can help to avoid social resistance from, for example, groups that fear that HPV vaccines will promote promiscuity (even though studies have shown that sex education has the opposite effect).5,79,80 Community readiness and acceptance will help to ensure access to vaccination and screening programs, so community leaders should be involved in the design and implementation from the beginning. Based on the results of extensive audience and systems research, all four country programs made the strategic decision to emphasize the protective effect of the vaccine against cancer rather than emphasizing the mode of transmission (sexual activity) or the disease agent (HPV) when educating community members. As mentioned in the HPV and cervical cancer section above, sometimes people assume that because both HIV and HPV are sexually transmitted, prevention strategies would be similar. In the early 1980s, certain HPV types were identified as the cause of cervical cancer by zur Hausen and colleagues. There is no treatment once a person acquires an HPV infection, but recently approved vaccines can prevent infection if given before sexual activity begins. Thus, there is typically a long delay between infection and invasive cancer.13,15,16 This is the reason that screening programs can be so effective, as discussed in the Screening and treatment section. They first become abnormal (precancerous), and after a time, they develop cancerous properties. These vaccines do not protect against all HPV viruses that can cause cervical cancer, so screening is still necessary. If characteristic, well-defined white areas are seen near the transformation zone, the test is considered positive for precancerous cell changes or early invasive cancer. VIA therefore can be used as a primary screening test or for treatment triage subsequent to primary Pap or HPV testing. The main benefit is that women are less likely to be lost to treatment because they cannot return to the clinic.47 Screen-and-treat programs have been evaluated in Ghana, South Africa, and Thailand with good results.
There are, however, effective and inexpensive options for providing pain control, such as the use of morphine. There also was concern that conservative religious leaders might take a stand against HPV vaccination for the same reasons. Conversely, the immunization community may have limited knowledge of cervical cancer and HPV.
When they invade the deep muscle and fibrous tissue, and then the organs surrounding the uterus, the patient has invasive cancer.
Because cervical cancer develops slowly, over years, regular screening, along with removal of any lesions, is very effective in preventing invasive cancer. Rather, cervical screening is the best approach for this group.1,36 Because the incidence of cervical cancer is highest in women more than 40 years of age, screening is especially important in older women (see Continued need for screening below). It is more sensitive than visual inspection methods and cytology, but it is unaffordable for low-resource areas.
According to this thinking, as cervical lesions become less prevalent, technicians will lose their skills of interpreting specimens, so the accuracy of Pap screening will fall. The results are immediately available, allowing treatment at a single visit and thus reducing loss to patient follow-up.
Both cryotherapy and LEEP are less radical than the previous standard treatment, cold-knife cone biopsy.
VIA’s sensitivity is as good as or better than that of the Pap smear, but like the Pap smear, visual inspection is subjective, and supervision is needed for quality control of visual inspection methods. More generally, the principles of public health screening will help to determine how resources should be allocated in future decades, taking into consideration factors such as vaccine coverage and cervical cancer prevalence.



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Comments to “Treatment options for cervical cancer”

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  2. 13_VOIN:
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  3. Lerka:
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  4. ALINDA:
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  5. plotnik:
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