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An Introduction to Dr. Franco

Cervical Cancer information provided by Dr. Franco.

“Julyna is a bold and innovative initiative by Canadian women who want to make a difference in cervical cancer prevention. It empowers women by increasing awareness about cervical cancer and the means to prevent it. It gives a voice to women in Canada who are affected by this terrible disease and want to do something about it.” --Eduardo L. Franco, DrPH, FRSC, FCAHS

Dr. Franco is James McGill Professor and Interim Chair, Department of Oncology, and Director, Division of Cancer Epidemiology, McGill University, in Montreal, Canada. His research during the last 27 years has focused on the epidemiology and prevention of cervical and other HPV-associated cancers, and upper aero-digestive tract and childhood malignancies.

He published over 350 articles, 50 chapters, and two books on cancer epidemiology and prevention. He has served in the editorial boards of the American Journal of Epidemiology, Cancer Detection and Prevention, Cancer Epidemiology, Biomarkers & Prevention, Epidemiology, eLife, International Journal of Cancer, Medical and Pediatric Oncology, PLoS-Medicine, and Preventive Medicine.

His distinctions include: Fellow of the Canadian Academy of Health Sciences (2012), Fellow of the Royal Society of Canada (2011), McLaughlin-Gallie Award, Royal College of Physicians and Surgeons of Canada (2011), Lifetime Achievement Award, American Society for Colposcopy and Cervical Pathology (2010), Honorary President, EUROGIN Congress, Monaco (2010), Women in U.S. Government’s Presidential Leadership Award (2008), EUROGIN Society’s Distinguished Services Award (2006), Canadian Cancer Society’s Warwick Prize in cancer control research (2004), Medical Research Council of Canada’s Distinguished Scientist Award (2000), and Educational Excellence at McGill University (2000).

Incidence of Cervical Cancer

Incidence of Cervical Cancer

  • It is estimated that 1300 Canadian women and their families will have to deal with the reality of a cervical cancer diagnosis this year alone
  • For every case of cervical cancer that is diagnosed and treated, there are between 50 and 100 women who are found to have cervical precancerous abnormalities
  • Diagnosing and treating these precancerous lesions cause considerable anxiety and may increase the chances that these women will have miscarriages in the future
  • Cervical cancer can affect young women in their 20’s and 30’s
  • It is the second most common cancer in women aged 20-44, after breast cancer
  • Essentially, all cases of cervical cancer are caused by a common virus called HPV
  • Approximately 75% of sexually active men and women in Canada will have at least one HPV infection in their lifetime. For some, this will lead to cervical cancer
Mortality and Prevention

Mortality

350 women in Canada still die of cervical cancer each year. The probability of surviving cervical cancer is lower than that of breast cancer.

Prevention

Luckily, women can prevent most incidences of cervical cancer by properly screening themselves for the disease. Once a woman is 21 years of age and has become sexually active she should have a Pap test at least once every 3 years. Human Papillomavirus (HPV) is the major cause of cervical cancer and is spread through genital skin-to-skin contact. There are two vaccines approved for use in Canada to prevent HPV infection. These vaccines should be viewed as a complement, not a replacement for cervical cancer screening.

The History of HPV

In 2008 the Nobel Prize in Medicine was given to Dr. Harald zur Hausen for the discovery of the human papillomavirus (HPV). He recognized that certain types of HPV infection cause cervical cancer. His discovery led to improvements in HPV prevention through screening and immunization.

While screening helps identify women who need treatment, with HPV vaccination we can prevent the HPV infection from occurring at all. In the past five years scientists have completed considerable clinical research proving that HPV vaccines are safe and effective. Today, many countries have incorporated prophylactic HPV vaccination in their immunization programmes.

HPV Viruses – What We Know and How they Work
There are more than 100 types of HPV. Some of them cause cancer and some are painful and inconvenient.

More than 40 types of HPV are mucosotropic, which means that they infect the moist mucosal areas of the body, such as the anogenital and oral tracts.

HPV types 6 and 11 are mucosotropic, but do not cause cancer. Instead HPV 6 and 11 cause visible growths or warty lesions, also called condylomas. Although benign, these anogenital warts from are obviously an inconvenience to the patient and cause much anxiety. Many tend to disappear spontaneously but recurrence is common. Treatment of these anogenital warts can be painful.

Roughly 25 types of mucosotropic HPVs can lead to precancerous lesions or cancer in the areas where infection becomes persistent. The most important carcinogenic types are HPVs 16 and 18, which are responsible for a little more than 70% of all cervical cancers. HPV 16 is also the dominant type in anal, penile, vaginal, vulvar, and oral cancers in which HPV is found to be the causal agent. Fortunately, both of the two HPV vaccines available currently protect against HPVs 16 and 18. One of these vaccines protects also against HPVs 6 and 11, thus preventing anogenital warts and reducing the risk of respiratory lesions.

How HPV is Transmitted

Genital HPV infection is acquired mainly via sexual intercourse in which one of the partners is already infected.

Condom use protects against sexual transmission of HPV infection. Oral HPV infection is acquired via oral sex and anal infection via anal sex. Like all sexually-transmitted infections, having multiple sex partners increases the risk of eventually being exposed to one who is already infected and thus of acquiring infection.

Most men and women who engage in sexual activity eventually acquire HPV infection. It is the most common sexually transmitted infection we know.

HPV and Men
Most men who get HPV never develop any symptoms or health problems. As it does in women though, some types of HPV can cause genital warts in men. For men, other types of HPV can cause cancers of the penis, anus, or oropharynx (back of the throat, including base of the tongue and tonsils.) Gay and bisexual men are more likely to develop HPV-related diseases than heterosexual men, and while there is no HPV screening test for men, HPV vaccines are effective for men.
Developing Cervical Cancer from HPV – Who’s most at Risk?

The prevalence of cervical HPV infection is highest soon after the onset of sexual activity in the late teen years to around age 25 and then gradually declines because of the immunity that develops, which helps the body to clear these infections to levels that are below detection.

In some populations we see a second peak in prevalence in women aged 45 to 55 years, possibly as a result of the hormonal changes during menopause, which bring a weakening of the immune protection that developed earlier in life and may cause some latent infections to reoccur. This second peak could also be a consequence of the changes in lifestyle (e.g., a divorce leading to new sexual partners later in life) and thus of new exposures to men infected with HPV.

Increased Risks for HPV and Cervical Cancer
If you acquire a cervical HPV infection that involves an oncogenic type of HPV, you are already at risk of developing cervical cancer. Your risk is even greater if you are a smoker, have had multiple pregnancies, or have made prolonged use of oral contraceptives. In addition, infections with other sexually transmitted agents such as Chlamydia and Herpes simplex increase the risk of cervical cancer in a woman who has an oncogenic cervical HPV infection. Some genetic characteristics that influence how the immune system reacts to infectious agents also play a role in the overall risk of cervical cancer.
How the Body Responds to HPV

The vast majority of cervical infections are transient. They last around 8 months and then disappear (based on the molecular tests we use clinically). If an infection lasts more than 12 months and happens to be by one of the main oncogenic (cancer –causing) types of HPV (for instance, HPV 16 or 18) then there is a good chance that the infection could have progressed to a precancerous cervical lesion. Fortunately, pre-cancerous lesions tend to regress naturally, particularly in young women. However, for a woman aged 30 years or older, having an oncogenic HPV infection that does not clear within one year is reason to see a gynaecologist. A gynaecologist will take a biopsy of the cervix, and then decide if treatment for a precancerous lesion is needed.

For people who have underlying conditions which affect their immune systems, HPV is an even greater concern. Diseases such as HIV infection or conditions such as immunosuppressive therapy (e.g., for those who undergo organ transplantation), weaken the body’s immune system and make people more prone to acquiring HPV infection that persists for a long time.

HPV Screening – Why it Matters and How it’s Improving

HPV is a slow and stealthy virus. I t may take from a few months to a few years for an HPV infection to become persistent and eventually cause precancerous changes in the cervix. It will take several years to a couple of decades more for these precancerous changes to become true cervical cancer.

Screening is the opportunity we have to detect these precancerous lesions early enough and then treat them so that cervical cancer will not occur. Molecular HPV testing is an exciting development in cervical cancer screening. Clinical trials have shown molecular HPV testing considerably improves the reliability of screening results. Molecular HPV tests use the same specimen that physicians collect for the Pap test, except that instead of smearing onto a glass slide, the collecting device (a cytobrush) is placed into a tube with a preserving fluid. Unlike the Pap test, which had about 45% false negatives, the HPV test has very few false negatives, thus it is a more sensitive test and can be easily applied for large numbers of specimens.

HPV Research in Canada

Canada has been a leader in research on cervical cancer and in HPV-associated diseases. It was the first country in the Americas to conduct publicly funded randomized controlled trials of molecular HPV tests versus Pap tests in cervical cancer screening. Canada was also a leader in the earlier clinical trials of HPV vaccination, completed in the mid-2000s. Canada was among the first countries to adopt publicly funded, school-based HPV vaccination, soon after Australia and the UK.

Canadian epidemiologists have also been pioneers in conducting studies of the natural history of genital HPV infection and of the risk factors that make women and men acquire such infections. There are major research teams in Quebec, British Columbia, and Manitoba that focus on the basic biology, epidemiology, and health economics of HPV infection and the diseases that it causes.

Much remains to be done and our Canadian teams are hard at work trying to understand how HPV can cause cancer in sites other than the uterine cervix. There is ongoing Canadian research on the role of HPV in oral and anal cancers and on the means of preventing these diseases.

HPV and Skin Cancer
In addition to the types of HPV that infect the mucosal surfaces of the body there are also HPV types that preferentially infect the dry skin. They are acquired by skin-to-skin contact. We have known for a long time about the warty lesions that can develop in the hands and feet. These lesions can be easily treated. Other types of skin HPVs are associated with some forms of cancer of the skin. There is much research that is ongoing in trying to understand how UV exposure exacerbates these infections, thus making them progress to skin cancer.
Breast vs. Cervical Cancer Risk Factors

Women with multiple pregnancies tend to have high risk of cervical cancer. These women are generally of low socioeconomic status; they have not been properly screened or not screened at all. All things being equal, breast cancer risk is affected by the age at a first full-term pregnancy; the later the age the higher the risk; with nulliparity (bearing no children) conferring highest risk. Since women who engage in university education tend to postpone childbearing for several years or indefinitely they end up with higher risks of breast cancer than those who have children earlier in life. Delaying the first pregnancy also decreases the window of reproductive opportunity for additional pregnancies. Being educated, these women are of higher socioeconomic standing and are receptive to health promotion messages and campaigns.

The end result of the above biological and socioeconomic differences in risk profile between these two diseases is a disparity in how the public perceives them. There is far more public perception and concern about breast cancer, despite the fact that it is not as preventable as cervical cancer.