Seeking clearer pictures
If caught early enough, cervical cancer is almost always treatable. Unfortunately, most women don't realize they have the disease until abnormal cells become cancerous and invade nearby tissue.
Christopher Crum, MD, and Sarah Feldman, MD, collaborate in the lab.
Several factors are thought to put women at greater risk, including smoking and a weakened immune system caused by HIV infection or immunosupressant drugs given during organ transplants. More than 90 percent of cervical cancer cases, however, are linked to sexually transmitted human papillomavirus that triggers the growth of abnormal cells that can lead to cancer.
"Most Americans between the ages of 18 and 25 — male and female — have been exposed to the HPV virus, with some studies showing exposure rates as high as 80 percent," says Berkowitz. "Once a person has had even one sexual partner, the chances are greater than 50 percent that he or she has been exposed."
He adds that incidence rates for the virus, which also causes genital warts, are likely to rise even more among individuals who become sexually active at an early age, have had multiple sexual partners, or whose partners have had multiple partners. Because no precancerous symptoms exist, DFCI and Brigham and Women's doctors point out, all women should receive regular Pap smears and pelvic exams to reveal any abnormalities in the cervix. New guidelines from the American Cancer Society (ACS) state that yearly Pap smears are no longer necessary in all cases (see http://CAonline.AmCancerSoc.org for more details), but pelvic exams should still be done annually.
"The purpose of Pap smears is to pick up precancers before they develop into cancer."
— Sarah Feldman, MD
"The purpose of Pap smears is to pick up precancers before they develop into cancer," explains Sarah Feldman, MD, a gynecologic oncologist with Dana-Farber and BWH. "You can't tell for sure from a Pap smear if somebody has cancer or not, but you can make an educated guess based on how abnormal the cells look."
One recent advance — a newer Pap smear known as the Thin Prep Pap Test developed by the Cytyc Corp. of Boxborough, Mass. — is making this process more reliable than ever. Instead of moving directly to a microscopic slide for examination as in traditional Paps, cervical cells in these tests are first placed in a liquid that separates them from red blood cells and other organisms. "The slides offer a much clearer picture of just the cervical cells," says Feldman. "For the patient, the thin-layer Pap smear takes no more time than a conventional Pap, and it is what most physicians, including those at Dana-Farber and Brigham and Women's, now use." (The new ACS guidelines recommend Thin Preps every two years.)
Once cancer is verified, treatment varies depending on the tumor's location and size and the stage (or extent) of the disease, as well as a patient's age and condition. For women with tumors classified as Stage 1A, surgery is recommended. If the cancer is pre-invasive and a patient is planning to bear children, her surgeon can often eradicate the tumor(s) while leaving the uterus and ovaries intact. If a cancer is more advanced, or invasive, a hysterectomy to remove the uterus is called for.
"Because of the wider use of Pap smear screening and advanced technology, we're able to identify tumors at much earlier stages and are seeing fewer advanced cervical cancers," notes Michael Muto, MD, one of the Gillette Center's surgeons. "The smaller the tumors are when we find them, the more likely we are to cure the patient while preserving her fertility."
Patients with more advanced disease (Stage 2A–4A) that can't be treated surgically — as well as a few post-operative patients whose tumors are larger or have spread to other areas — often must undergo an aggressive regimen of radiation and chemotherapy.
One physician, Akila Viswanathan, MD, evaluates, plans, and leads all radiation treatment for patients seen in the center. Consulting with other members of a patient's care team, she maps out a combination of daily external beam radiation and a few sessions of brachytherapy — a powerful internal procedure in which cancer-fighting radioactive sources are temporarily implanted inside a patient's body at or near tumor sites. This offers a way to focus the strongest possible radiation where it's needed most while striving to protect nearby organs and normal tissue.
"High-dose brachytherapy gives patients the option to receive all of their radiation treatment as outpatients," explains Viswanathan, one of several new physicians — along with Kristin Keefe, MD, and Elizabeth Onyemelukwe Garner, MD — to join the Gillette Center's expanding staff in the past year. "Before it was introduced a few years ago, low-dose brachytherapy was the only alternative, and patients receiving it had to stay in isolation at the hospital for five days. Now patients can come in for just five outpatient sessions over two-and-a-half weeks, interspersed with their external radiation treatment."
"The most amazing thing about my care was how closely the doctors and nurses worked with me and with each other."
— Patti Saganey
For most patients, external beam radiation is a short outpatient procedure that takes place weekdays for a month or more. One day each week, they also receive chemotherapy, which takes several hours and is supervised by medical oncologists including Campos and Ursula Matulonis, MD, who team with Viswanathan and the center's surgeons. "The multidisciplinary approach is very important," says Campos. "By coordinating our specialties, we can make everything come together nicely for the patient. Each discipline complements the other."
Patti Saganey is one patient who has benefited from this synergy. The 35-year-old Easton, Mass., resident had always undergone annual Pap smears but never had an abnormal screening until last June. When her doctor sent her to Dana-Farber, she was diagnosed with Stage 1 cervical cancer and immediately scheduled for a radical hysterectomy by Muto to remove her uterus, cervix, and surrounding tissue. Because her tumor was large and had invaded her cervix and other areas, she was put on a five-week course of radiation and chemotherapy.
"The most amazing thing about my care was how closely the doctors and nurses worked with me and with each other," recalls Saganey, a mother of two who returned to full-time work in December and is now training for August's Pan-Massachusetts Challenge bike-a-thon to benefit Dana-Farber. "Dr. Viswanathan was wonderful in explaining the entire radiation process, and nurse Catherine Duggan always knew by looking at me how I was feeling and what she should say. Drs. Campos and Muto were great as well; I put my faith and trust in all of them, and everything worked out."
Viswanathan and other radiation oncologists are also encouraged by the results of a new approach in which chemotherapy and radiation therapy are given concurrently. "There has been an approximately 20-percent increase in five-year survival rates shown in five large, randomized trials," she says. "This is the way oncology is moving — and it's the most significant rise in survival rates for cervical cancer that we've seen since the advent of radiation."
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