Cervical Cancer and HPV Vaccine

By Tanya Gallant MSII Northern Ontario School Of Medicine

What is cervical cancer?

Cervical cancer is when the normal cells in the cervix grow out of control and have an ‘abnormal’ appearance (Canadian Cancer Society, 2009). Women whose cervical cancer is found and treated early typically do quite well. This stresses the importance of finding the cancer early.

In Canada, 1300 new cases of cervical cancer will be diagnosed in 2011 and the chances of a women developing cervical cancer is 1 in 153 (Canadian Cancer Encyclopedia, 2011).

Approximately 350 women in Canada will die from it this year (Canadian Cancer Encyclopedia, 2011).

What are the common signs of cervical cancer?

It is important to note that many women do not feel any symptoms at first, but the most common symptom that women experience is bleeding from the vagina. Bleeding may happen after sex, between menstrual cycles, and after menopause (Canadian Cancer Encyclopedia, 2009).

Is there a test for cervical cancer?

Yes, there is! There is a test called the ‘Pap test’ that is used to screen women for cervical cancer. Women who are 18 years old or who are sexually active should get screened (Canadian Cancer Encyclopedia, 2011). Once you go to your appointment to see your doctor, he/she will take a look at the walls of your vagina by using a thing called a speculum. The testing part is by taking a painless swab of cells from the cervix (hence, cervical cancer) and sending them to the lab to have them checked under a microscope.

If the cells are normal, women normally are checked every 1 to 3 years until the age of 69 or until the doctor finds something abnormal (Canadian Cancer Encyclopedia, 2011).

If the cells are abnormal, the doctor will have you come back to see whether follow-up testing is needed (Canadian Cancer Encyclopedia, 2011).

A new cervical cancer test is being considered on PEI to replace the test just mentioned. It will test for both cancer and the human papillomavirus (discussed later). It is currently being tested in Newfoundland and Labrador, New Brunswick and Ontario (CBC, 2011).

How do we treat cervical cancer?There are three main ways that we treat cervical cancer (Canadian Cancer Society, 2009):

- Surgery

- Radiation therapy

- Chemotherapy

After a person has had treatment for cervical cancer, they will need to be checked from time to time to see if the cancer has come back or if the cancer has spread.

How can I prevent cervical cancer?

The human papillomavirus vaccine is now available.

What is HPV?

HPV stands for the human papillomavirus. It is spread by skin-to-skin contact and sex (CDC, 2009). HPV causes up to 70 percent of cervical cancers (CBC, 2011).The risk of getting HPV increases with the number of sexual partners you and your partner have had.

If HPV is so common, why should I be concerned?

The majority of the people infected with HPV fight off the virus within two years of getting it, typically without treatment (CDC, 2009). Unfortunately, a small amount of people cannot seem to get rid of the virus. In these people, there is a greater chance that HPV will turn into cancer. This stresses the importance of getting tested regularly.

What is the HPV vaccine?

At the moment, two types of vaccine are available: Gardasil and Cervarix (Public Health Agency of Canada, 2010).

Gardasil is given by three different vaccine shots, which are given two and six months after the first. It protects against HPV types 6 and 11, which cause 90% of genital warts, as well as HPV types 16 and 18, which are high-risk types and cause about 70% of cervical cancer (Gardasil, 2010).

Cervarix is also given by three different vaccine shots, which are given one and six months after the first. It protects against HPV types 16 and 18, which cause 70% of cervical cancer (Cervarix, 2010).

Who should get the HPV vaccine?

The HPV vaccine in the US is recommended for all girls and women between the ages of 9 and 26 years (Public Health Agency of Canada, 2010). Both vaccines work best if given before a person starts having sex because the vaccine does not get rid of it once you have it. The vaccine may still give some protection to those who are under the age of 26 and sexually active, as well as have genital warts, a positive HPV test, and/or an abnormal Pap test (Public Health Agency of Canada, 2010).

Where can I get more information?

Your health care professional is your best person of contact for any questions or concerns you may have.

The Canadian Cancer Society has a great user-friendly website on cervical cancer that can be found by pushing this link: http://www.cancer.ca/Canada-wide/About%20cancer/Types%20of%20cancer/What%20is%20cervical%20cancer.aspx

The Public Health Agency of Canada has a great site on the safety and effectiveness of the HPV vaccine: http://www.phac-aspc.gc.ca/std-mts/hpv-vph/fact-faits-vacc-eng.php

Concussions and Post Concussion Syndrome

By Adam Kading MSIV Dalhousie Medical School

Concussions have become a mainstream topic in recent years. Here in Canada we have constant exposure to news of concussions. It seems like every week during the hockey season, another player has been sidelined with post concussion syndrome. Of course, concussions do not occur only in the setting of sports. This article will shed some light on exactly what concussions are, how to manage them, and why symptoms can persist.

What is a concussion?

The brain is protected inside the head by the thickest bony structure in the body, the skull. The skull does a remarkable job protecting the brain from injury. However, when force from injury is severe (for example: a bad fall, car crash, or having a shoulder collide with your head) the brain smashes against the inside of the skull producing injury. In most cases the injury causes unseen damage to the nerves of the brain, or bruises in the brain matter. In more severe injuries, bleeding inside the skull and brain death can occur. Thankfully, severe injuries like this are much less common, tend to be associated with the severity of injury, and produce recognizable symptoms.

What are the symptoms of concussion?

The most common immediate effects of a concussion are loss of consciousness, confusion, and amnesia (forgetting the event). However, not everybody will experience these and they are not necessary for diagnosis. Common symptoms occurring minutes to hours after a concussion are headache, dizziness, nausea and vomiting, fatigue, difficulty concentrating, and memory problems. Sometimes people will experience emotional changes days to weeks after an injury. Anxiety, depression and post traumatic stress disorder occur frequently after head injury. Occasionally personality changes can be seen. If you are experiencing any of these symptoms or if you have had a head injury you should see a doctor in a timely fashion.

Symptoms that can indicate that a severe brain injury has occurred are difficulty waking the person, seizures, vomiting many times, an obvious skull fracture, and weakness or numbness in the body. If these symptoms are occurring in yourself or someone you know, call 911 or get to an emergency room right away! 

How long will symptoms last and what is Post Concussion Syndrome?

Post concussion syndrome refers to symptoms of concussion that persist after the trauma has occurred. Common symptoms include headache, dizziness, difficulty concentrating, persistent fatigue, irritability, and mood changes but the range of symptoms is extensive and includes the ones listed above and more. These symptoms tend to be brought on or made worse with anything that stresses the brain. This includes talking, reading, watching TV or exercising. The vast majority of people with first time head injuries will improve after approximately one week. In these people the injuries to the nerves of the brain heal without permanent damage. Most others will be back to normal by 3 to 6 months. Approximately 10 % of people will still be experiencing symptoms at 1 year. A small number of people can be left with permanent symptoms and disability. Unfortunately it is difficult to predict who will have long lasting symptoms as length of symptoms is not necessarily associated with the severity of the injury.  It is believed however, that post concussion syndrome lasts longer in people who have experienced multiple past concussions.

How do we manage concussions?

Unfortunately there are no great medical treatments to improve concussion symptoms. An injury to the brain is treated in much the same way as an injury to any other part of the body. If you break your arm you need to rest your arm until complete healing has occurred. The same general idea holds true for the brain. Immediately after a concussion the brain needs rest. It is recommended that for the first one or two days after a head injury that you rest in a quiet room. This means no stimulation. No reading, no TV, no conversations, no stress. You should sleep as much as needed. Frequently people are concerned by the need for extra sleep following a concussion. This is actually a normal and expected consequence of an injury. The brain heals best when sleeping.

            It used to be common practice to recommend waking a person with a concussion every several hours following injury, the general idea being that family members might be able to pick up on a serious injury. This is no longer recommended. It is difficult for family members to assess a sleepy person and it likely only contributes to anxiety while not allowing the injury sufferer the time to heal. That being said, the concussion sufferer should be checked on regularly. If there are concerns regarding breathing or how they are sleeping they should be woken up and checked out by a doctor.

            After you no longer have symptoms at rest you can slowly resume activity. The essential rule is start low and go slow. Basic activities like walking, talking, light chores, and reading can be attempted. If any of these activities bring on symptoms mentioned above, then the activity needs to be stopped. You have pushed your self too far and need to return to rest. You need to resume light activities slowly and need to learn how long you can engage in them before experiencing symptoms. If symptoms are experienced after 20 minutes of walking, walk fifteen minutes next time and gradually increase this amount day to day.

            Over time the light activities can progress to more intense activities such as exercising or returning to work/ school. The same principle applies here as to the other stages. If these activities bring on symptoms then return to lighter activities and do less the next time. If returning to a contact sport, then contact should be resumed only after you are symptom free after performing significant amounts of intense exercise.

            There are many guidelines available on managing concussions. The link below was published by Think First and is geared towards contact sports, but the first several stages can be applied to anyone with a head injury. Think First Concussion Handout

Long term outlook

The general outlook for people with mild concussions is good. Most will improve within 1 week and the vast majority will be back to normal by 6 months. If your symptoms have lasted longer than a year there is a chance that some symptoms will be permanent. Repeated concussions can cause several problems. The more concussions you have had, the longer post concussion symptoms will tend to last. People who experience many concussions over their life like boxers or other pro athletes are prone to dementia. This includes permanent forgetfulness, chronic headaches, loss of concentration and personality changes.

Important Points

1. If playing sports and an athlete experiences a head injury they need to be removed from play immediately. This is to reduce the likelihood of experiencing a second concussion. Back to back concussions can cause second impact syndrome, a rare but fatal complication where the brain swells inside the skull.

2. It is essential that you be symptom free before returning to sports or normal day to day activities. One reason for this is to avoid the second impact syndrome mentioned above. Another reason is that ignoring post concussion symptoms can make them last longer. Finally, returning to play while still experiencing symptoms makes a second concussion more likely. You can get a concussion with less head trauma than normal if you still have post concussion symptoms.

3. Be aware of feelings of anxiety or depression. Mood symptoms frequently occur in people with long term post concussion symptoms. This is thought to occur due to injury to the brain and also due to the lifestyle changes that inevitably occur. If you are feeling irritable, on edge, depressed, not sleeping well, having flashbacks, or having bad dreams see your doctor.

Works Cited

CMA Policy. Head Injury and Sport. Publication. Ottawa: CMA, 2011.

DeKosky, Steven T., Milos D. Ikonomovic, and Sam Gandy. "Traumatic Brain Injury — Football, Warfare, and Long-Term Effects." New England Journal of Medicine 363.14 (2010): 1293-296.

Fann, J. R. "Psychiatric Illness Following Traumatic Brain Injury in an Adult Health Maintenance Organization Population." Archives of General Psychiatry 61.1 (2004): 53-61.

Kissick, J. "New Concussion Management Guidelines: Concussion Question and Answer Document For Physicians." Think First, June 2005.

Putukian, Margot. "The Acute Symptoms of Sport-Related Concussion: Diagnosis and On-field Management." Clinics in Sports Medicine 30.1 (2011): 49-61.

Think First. "CONCUSSION: GUIDELINES FOR PATIENTS, FAMILY MEMBERS & CAREGIVERS." May 2007.

Prostate Cancer Screening: To screen or not to screen…

By Daniel Keefe MSI Dalhousie Medical School

What is the prostate?

The prostate is a gland found only in men that is about the size of a walnut. It is found just below the bladder and surrounds the urethra (the tube that brings urine to the penis when urinating). It produces fluid that helps make up semen. Naturally as men age, the prostate gland will grow in size.

The Facts about Prostate Cancer

Prostate cancer is the most common cancer in Canadian men (1 in 7 will be diagnosed in their lifetime) (Prostate Cancer Facts). Prince Edward Island has the highest occurrence rate of prostate cancer in Canada, and it is the second leading cause of cancer related death (behind lung cancer) among Canadian men (PEI Cancer Stats 2011).

Alright you have my attention now. How can I avoid developing prostate cancer? How do I know if I’m at risk?

Healthy lifestyle habits such as regular exercise, not smoking and minimizing how much salt and fat you eat can lower your risk of developing prostate cancer. African-Canadian men and men with close relatives (father or brother) that developed this cancer before age 65 are at increased risk.

How would I know if I had prostate cancer?

Prostate cancer is a very slow growing cancer and that symptoms may only develop after years of tumour growth. Essentially, it is possible to have prostate cancer without ever having any symptoms. It is for this reason that screening is important to discuss even without symptoms. However, some symptoms attributed to prostate cancer include: urinating more frequently, waking to urinate at night, having to strain to urinate, not feeling ‘empty’ after urinating, and difficulty initiating urination. It is important to realize that these symptoms may be caused by other health problems (e.g., infection) and do not mean you have prostate cancer. If you are experiencing any of these issues be sure to go see your doctor (TOP-PROCAP Clinical Practice Guidelines).

Screening for Prostate Cancer – Ask your Doctor!

The goal of screening is to detect cancer before it rears its ugly head. It is important to discuss getting screened for prostate cancer even if you don’t have any symptoms.

You should discuss screening with your doctor if you are:

- Over the age of 50

- At a high risk of developing prostate cancer (a strong family history of this cancer or if you are African-Canadian)

- Or, if you are concerned about developing prostate cancer

If you choose to undergo screening, there are two recommended screening measures which should be used in combination: the digital rectal examination (DRE) and prostate-specific antigen (PSA) test.

DRE: this exam is used to directly examine the prostate by inserting a gloved and lubricated finger into the rectum. Your doctor can check your prostate for any abnormal lumps or an increase in size of the prostate, which would warrant further investigation.

PSA: the prostate produces a protein that is present in the blood of all men. By sampling your blood, the quantity of this protein (PSA) can be measured. If the quantity of the protein in your blood is higher than normal for your age group it is an indicator for potential prostate abnormalities. A high PSA does not mean you have prostate cancer as infections, or benign growths can also increase your PSA numbers. (Patient Education)

What if I have a positive screening test?

If either of these tests is abnormal you may be referred to see a physician who specializes in this area, known as a Urologist. Using an ultrasound-guided needle, the urologist will sample the cells of the prostate to diagnose or rule out prostate cancer. This is known as a Trans-Rectal Ultrasound (TRUS) guided prostate needle biopsy.

How often should I get screened for prostate cancer?

If you have a normal DRE and PSA test you can be tested every two years. If you have a normal DRE and a slightly elevated PSA it is important to recheck your PSA levels yearly to monitor progression.

What you need to know before getting screened. The great debate!

The fact is most people will die with prostate cancer and not from it! In other words, although many men will be diagnosed with prostate cancer, it will not cause their death. Prostate cancer screening is the centre of a continuing debate of its benefits. Let us discuss the pros and cons (Interesting article):

Pros:

- The PSA test is a good predictor of prostate cancer risk (higher PSA value means a higher risk of prostate cancer)

- Earlier detection of prostate cancer leading to better treatment options and outcomes

- Regular PSA tests and DREs can monitor the progression of prostate cancer in those that have been diagnosed but where treatment is not warranted as of yet

Cons:

- Prostate cancer is being detected in more men leading to overtreatment of disease that may never cause any problems in a man’s lifetime.

• These treatments include radiation therapy and radical prostatectomy (surgery to remove the prostate).


• The risks of these treatments are significant: incontinence (inability to control urination and possibly constant leaking), impotence (inability to achieve erection) and rectal dysfunction have huge impacts on a man’s quality of life

- High rates of false-positives. In other words, patients may have a positive test when the patient does not have prostate cancer

- Screening may suggest no cancer in a patient that does have cancer (false-negative) which gives patients a false sense of security

- More screening leads to more biopsies putting patients at increased risk of infections, blood in urine and pain.(Cochrane Library 2006)

The bottom line:

Prostate cancer screening is a beneficial tool to detect disease in the earliest and most treatable form. However, statistics from the largest trial analyzing this screening has shown that we would have to screen 1410 men before saving a single life due to this disease. Some perspective: there are approximately 25,000 men over the age of 50 in PEI. We would have to screen each of these men every 2 years for 10 years to prevent the death of 17 men.

Furthermore, because it is such a slow growing cancer, screening of men not expected to live more than 10 years does not have any benefit and should be avoided. (European Randomized Study of Screening for Prostate Cancer (ERSPC) trial).

More information about screening can be found here and here.

An article that provides examples of the risk of Prostate Cancer screening from the Huffington Post

Teachers and Lessons

Not every teacher is human, not ever question answerable.  

Some lessons are learned after the teacher has left. 

So, this thing on my chest, it has gotten bigger and darker, should it come off?

OK, you have this mole on your chest that you have been watching for a while, and suddenly it starts to change, how do you know when it is time to remove it?  How can you tell if it is something worth worrying about?  What if it is a melanoma?  Today we are going to talk about just that.

What is a Melanoma?   A melanoma is a skin cancer that grows out of the cells in your skin that have color (melanin) in them.  These are the same skin cells that get darker as you tan.  After repeated intense irritation these cells can develop into cancers.   There are four distinct types based on how they grow and spread, and it is this growth and spread that make them so dangerous.  

•  70% are superficial spreading melanomas that spread out, slowly enlarging, becoming irregularly shaped with variations in color prior to growing deeper.  
•  15% are nodular melanomas that spread deep quickly and are usually blue-black, with occasional ulcerations
• 10% are acrolentiginous and mucosal melanomas that occur on the palms of the hands and soles of the feet as well as the nail beds and lips/nose on the moist surfaces.  These can occur in people of any skin color at equal rates, and grow outward first and then deep.
• 5% lentigo maligna melanoma with is in the sun exposed areas (90% face, neck, back of hands, lower legs) in older patients with variable coloration and slow expansion followed by increasing depth

Ok, so who gets these things?  These are cancers that occur as we get older (30-60 years old) and with the exception of the acrolentiginous type, occur primarily in light skinned individuals (Archives of Internal Medicine 2006 and International Journal of Cancer 2010).  The sun appears to be important for causing these cancers, and it is the intense sun that causes burns that seems to be the worst offender (Dermatology Surgery 2006).  Also, the number of freckles that you have increases your risk of melanoma (although it is not clear if this increases the risk, or makes them harder to find (Journal of National Cancer Institute 2003).  Finally, the use of tanning beds is associated with the increased risk of developing melanoma (Journal of American Academy of Dermatology 2005). 

I have a lot of freckles, how do I know if one is going bad? Dermatologist use the ABCDE rule to help us figure this out.  This simple rule looks at several aspects of a lesion to help (Journal of the American Medical Association 2004)

 A is for asymmetry.  Is the mole in question symmetric, that is, if you split it in half would both sides look the same?

B is for border.  Is the border of the mole sharp and regular?  Or is it shaggy and irregular?

C is for colors.  Are the many colors in the mole?  Is this mole differing shades of brown, black, gray, or white?

D is for diameter.  Is this mole bigger than 6 mm (the size of a pencil eraser)?

E is for evolution.  Has this mole changed  in the recent past?  Is it getting bigger?  Changing color? Bleeding?  Starting to itch or hurt?

These are the signs to watch for to help you figure out if it is a mole that warrants a closer look, and by a closer look, that means a biopsy.  The only way to know for sure if a mole is a melanoma or not is to cut it out and examine it under a microscope.  IT is by looking at the mole under to microscope that both he accurate diagnosis can be made, and the severity of the melanoma can begin to be judged.  It is most important for a melanoma to know how deep it goes, this is a key to knowing what should be done to treat it.

Ok, so if it is a melanoma can it be cured?  Well that all depends on how deep it goes.  The key element to cure is finding the melanoma early and cutting it out before it gets deep enough to spread to other places.  If it is thin enough, then the biopsy itself may be curative.  In many cases a repeat surgery is performed to take out a wider margin of healthy tissue to reduce the chance of spread.  For folks unfortunate enough to have a melanoma that goes deeply, there are many new drugs that seem to hold a lot of promise for treatment, but again the key is finding them early.

So, the key element is finding these things early, and that takes vigilance on your part, and the part of the medical team.  If you are at high risk, then it is worth your time to come in and be seen.  Having a close inspection of your skin on a regular basis is probably prudent if you are at high risk.  Of course, it should go without saying that protection from the sun is intensely helpful.

For more information on melanoma, please check out the following web sites.

The American Society for Dermatologic Surgery has a good self examination kit available 

The American Academy of Family Medicine has several good handouts of melanoma, checking for skin cancer, and prevention of sun damage.

Next week a guest article on Prostate Cancer.