Dr Timothy Oluwasola, a consultant obstetrician and gynaecologist at the University College Hospital (UCH), Ibadan. In this interview with Sade Oguntola, he explains why cervical cancer often presents without symptoms in its early stages, making regular screening vital for sexually active women, regardless of age, marital status or number of sexual partners. Excerpts:

What is a Pap smear test, and how is it different from an HPV test?

A Pap smear actually tests for the changes in the cells of the cervix, the mouth of the womb, to see whether there are changes on it suggestive of a persistent infection that may eventually lead to cancer. The rationale behind this is that the time between when the cervix shows these changes and when the cancer itself will start can take as long as eight to ten years. So, these changes be detected through a Pap smear test.

Now, human papillomavirus (HPV) is the actual virus responsible for cervical cancer. There are about 100 different types of HPV, but few of them are really very responsible for cervical cancer. Commonest in this group are HPV type 16, HPV type 18, HPV type 31 and HPV type 33. We call them high-risk HPV types because the potential of them eventually causing cervical cancer is higher compared to the low-risk HPV types.

The main issue about HPV infection is its persistency; when someone becomes infected with even the high-risk HPV types, the body can clear them off with time. But when the infection persists, maybe because of repeated reinfection, over time it causes a persistent change in the cells of the cervix that can lead to cancer. So, what does the HPV test entail? It tests for the virus; it gives evidence that the individual has become infected with the virus. A positive HPV test result, however, does not automatically translate to the person having cancer eventually. So, the two are different, but the two tests can add up to indicate whether an individual has a very high risk for developing cervical cancer.

It is said that most viruses run their course and go away without drugs. Is that not the case with HPV?

Yes, it depends on the type of virus. There are several types of viruses, and they affect different parts of the body. What they do depends on which type of virus and which part of the body is exposed. The HPV has a special interest in the lining of the body, so you find it affecting the lining of the vagina, the throat, the vulva, the anus and so on, where it normally hides. In the mouth, it is responsible for throat cancer. The HPV is also responsible for some penile and vulvar cancers.

For example, some respiratory tract infections are caused by viruses; they run their course, and then they go their way. The main problem with HPV is its persistency, sometimes because of continuous re-exposure. For example, a woman acquired an HPV infection from a man, and before her body cleared that infection, she had acquired another one. It could be because maybe she has different sex partners, so it becomes a problem for her body to handle.

So, does a Pap smear test detect cancer or just precancerous changes? Also, how accurate is it?

A Pap smear test is not for detecting cancer; in fact, when someone has the characteristic pattern that resembles cancer, there are other tests that we do. This includes a colposcopy and biopsy to pick up cancer at a very early stage that the mere eye cannot see.

Are there things that can negate good Pap smear results?

Before taking a Pap smear test, there are some instructions that are given. There can be a false report if it is taken a day after sexual intercourse, in the presence of infections such as vaginal infections or pelvic inflammatory disease, if menstruating or breastfeeding, or after a recent pregnancy. After pregnancy, the woman needs to wait at least six weeks before having a Pap smear test. Women on some types of contraceptives that can cause hormonal changes also need to state it so that the pathologist would be able to interpret the results based on the types of hormonal contraception they are using. Of course, douching should be avoided days before the test.

How true is it that a Pap smear cannot detect all HPV-related abnormalities?

The low-risk HPV usually causes genital warts; you do not need a Pap smear to detect this. The Pap smear is not designed to detect HPV; rather, it is looking for evidence suggestive of the presence of that virus.

Does it therefore require a woman to have both a Pap smear and HPV testing to be really sure of her status?

It is really not necessary to have the two; you can access either of the tests. Both will give evidence of having been exposed or currently being exposed to the virus. Now if you are exposed to the high-risk virus, what we do next is assess the cervix through a microscope to see whether there are obvious changes on the cervix and to treat it instantly. So, if you are in a place where an HPV test is not available, you can do a Pap smear. A Pap smear is looking for the evidence of the presence of that HPV; it is not telling you the particular type of HPV. Somebody who has pelvic inflammatory disease that one is not aware of may have some changes in the cervix that will make it look like early changes of cervical cancer. In fact, occasionally when we have patients with CIN1, we ask them to take specified antibiotics and repeat the test in six months because by then a number of them will now present with normal results.

Do HPV and cervical cancer present without symptoms?

Yes, HPV infections most of the time do not give any symptoms; many times individuals wouldn’t have a particular symptom, except people who have genital warts. Most of the time, those are immune-compromised, like people having HIV coexisting with HPV infection. Also, cervical cancer, like most cancers in the early stage, doesn’t have any symptoms. At the early stage, cancer changes are at the cellular level; as such, there are no obvious symptoms or signs. It is usually very silent, but it’s a dangerous silence. That is why regular screening is important. Many people have escaped having cervical cancer because they had a Pap smear test, and things suggestive of a possibility of cancer in years to come were detected and treated instantly. They don’t have cancer yet, but there are things suggestive of a possibility of cancer in years to come. Most cancers, by the time they begin to show symptoms or signs, have already advanced most of the time.

How best is the test results for the Pap smear test or HPV handled?

The standard thing is to accumulate your test results so that every year the expert can compare what it was last year and what it is now. There is a long time between when the changes in the cervix are seen and cancer develops. So, the essence of screening is to continually monitor the changes taking place on the cervix. The first one gives a baseline. If the result comes out normal, we’ll tell the woman to screen again in three years. If, for example, the next result comes back and there is CIN 1, we’ll say take antibiotics and repeat the test in six months. However, if the repeat test comes back as CIN 2, we counsel the client on the implications as well as available treatment options and thereafter request yearly follow-up care. However, if the changes become persistent, you begin to talk about possible management of that particular disease.

Are there lifestyle habits that women can adopt to reduce their risk of developing cervical cancer? Will things like douching be helpful?

Douching will not prevent cervical cancer. The only thing that can prevent cervical cancer is to ensure that you prevent an infection with high-risk HPV. Don’t be infected at all. If you must, then be sure it is not the high-risk HPV. But you cannot be asking everybody, “Do you have the high-risk HPV?” After all, we already know that it does not give any characteristic sign or symptom. So that is why having a regular, constant sexual partner is important. Also, a strong immune status to be able to clear any form of virus or infection off one’s body is vital, the same as safe sex practices and general body hygiene.

And then do a regular screening. Any woman that has had sex, even if it’s once, should ensure that she has a regular Pap smear or HPV screening. Some people say, ‘Oh, I have only one sexual partner,’ but you’re not sure whether your sexual partner has other sexual partners. And so, because of that small possibility, it is good for you to ensure that you do a regular check. And if you have a screening test that is positive, don’t throw it away and say it’s not your lot. By the time they come back again, the disease will have become full-blown. Likewise, indulgence in other sexual orientations, like anal and oral sex, increases the possibility of acquiring HPV. All these are steps to reduce the risk of having cervical cancer or its complications. Additionally, vaccination of young girls is a major breakthrough for the prevention of cervical cancer, and every patient should therefore ensure their girls are vaccinated.

Is there anything else about Pap smear screening in Nigeria that you feel is important that we have not discussed?

Yes, it is about the challenges. One, there are few centres offering Pap smears. Two, cost is an issue; most people can’t afford it. For those who can afford it in those centres, there is a delay in getting results because there are a limited number of pathologists that can interpret Pap smear results. There are about five such pathologists in Oyo State. Some available ones in Nigeria are even planning to resign. The turnaround time for the result had increased from about two weeks to three months. So, for some who have very positive results that will require immediate treatment, that delay may be dangerous.

The other part of the challenge is that not many people are interested in training as cytopathologists (pathologists that can interpret the slides from Pap smears). A number of doctors that should have been interested in the training have left the system.

Moreover, there are very limited labs in Ibadan that can run an HPV test. But if more people agree to check their cervical health, then we can have more centres where they can take Pap smear tests. One of the things we are considering in our department in conjunction with the pathology department is to have some external pathologists help us have a look into those slides at their leisure time. This can be done by telemedicine. That is why I didn’t want to put so much emphasis on the fact that there are not many pathologists.

But the take-home lesson is that everybody should be concerned about the mouth of their womb. Cervical cancer is preventable; it is treatable if picked up very early. The success rate of its treatment can be as high as 100 percent if picked early. In the past, we were told that cervical cancer is the disease of those who have plenty of children, maybe six children and above, and is more common in women aged 60 and above. But that epidemiology has changed. Even people who have not had any children before are having changes in their cervix that are predisposing them to cervical cancer. From research, earlier-age onset cervical cancer is increasing. And it is usually very aggressive in that age group. Because many of them are still regularly menstruating, they confuse the bleeding from the cancer with the regular menstruation. So it becomes a problem to identify.

Even when they complain at the hospital, some doctors do not even check why they are bleeding. They just give them medicine and send them back. So by the time they come to the teaching hospital, this cancer has gone beyond what can be treated. We see them a lot these days, so that is why everybody should be concerned.

Why are younger women now having cervical cancer? Is it due to their diet or what?

I won’t blame the diet alone. I think there are many fantasies that people play with now, especially with respect to sex and having multiple sexual partners. Also, sexual debut is about 11 years. It’s a major concern for cervical cancer incidents in Africa. The earlier you start engaging in sex, the higher the risk of you having HPV. That is one of the reasons why the government is saying vaccinate girls against HPV between the ages of 9 and 13. One of the things that we know contributes to the changes in the cervix is smoking. More young ladies now smoke. This affects the linings of membranes, speeding up damage to them when there is a persistent HPV infection.

Moreover, the fact that we now have the expertise has improved the diagnosis of cervical cancer cases. We have been encouraging all doctors to look into the vagina for what is causing the bleeding when a woman complains of having vaginal bleeding. Not only that, but some sonologists are also able to look into the cervix from the ultrasound. And they are able to decide if the cervix is bigger than expected and get the woman to go and get checked.

If there is no new case of cervical cancer in Nigeria from today, with the ones that we have already, we can’t finish taking care of them in the next 10 years because there are plenty. It’s the second most common cancer in women after breast cancer in women. (Nigerian Tribune)