HPV virus and cervical cancer

HPV virus structureHPV virus is a topic of interest in public health sites, blogs, magazines and it particularly affects sexual health as it is related to our sex life, is very frequent indeed, and was up to recently virtually unheard of. Even now it is treated with prejudice and misconception. Let us follow a TRUE-FALSE topic review and hopefully cover all questions and related issues.

The HPV virus is a recently developed virus that did not exist in the past, exactly like the HIV virus.
FALSE. The virus has always been around, we were just not aware of its existence and its mechanism of action towards disease.

It has been incriminated as a predisposing factor for cervical cancer, but there are cases of cervical cancer not related to HPV infection, exactly like there is lung cancer not related to smoking.
FALSE. The natural history of cervical cancer is unique in its exclusivity. It is always related to a HPV infection that took place at some point. In other words, there cannot be cervical cancer without a pre-existing HPV infection. No other cancer is thus exclusively related to a single aetiologic factor. Indeed, smoking does not have such a strong association to lung cancer pathophysiology, as it seems to be the case with HPV and cervical cancer.

HPV infection almost always results from sexual intercourse.
TRUE. It seems that vaginal penetration is the main way of transmission, that is why condom use offers significant protection (by 70%). However, transmission has been reported to occur even upon simple external close contact of affected genitalia, even when no penetration takes place, as is the case in female homosexual intercourse.

The HPV infection is rather rare and most frequently related to multiple sexual partners.
FALSE. This is a very frequent infection. The life-time infection risk for an average woman is estimated to be up to 80% and it is obvious that the timing of infection most frequently coincides with the first decade following initiation of sexual activity. Multiple partners as well as multiple previous contacts of those partners apparently facilitates the viral spread.

There are several HPV viruses with different behaviour and varying oncogenic potential.
TRUE. More than 120 different HPV viruses have been identified. Some viruses ( namely, HPV 6 and HPV 11) are related to benign skin condylomata (warts), whereas other HPV strains will cause pre-cancerous lesion within the cervix, some (notably HPV 16 and HPV18) are aggressive, others have lower oncogenic potential and are deemed low-risk. However, multiple strains may infect simultaneously and a combined picture of external warts and internal cervical lesion frequently ensues.

External warts are also related to cancer.
FALSE  External skin warts, usually located on the skin of the genitalia and the perianal area, may grow bigger and expand in the nearby skin. They may provoke discomfort but they do not turn into cancer. This is why HPV infection in men is not related to malignancy. Having said that, an extreme rare penile HPV-related cancer is  described, warts therefore should always be treated.

The virus may be transmitted through simple direct physical contact.
FALSE The current literature is rather vague, yet it seems that transmission is not possible through everyday contact, hand-shaking, hugging, common use of kitchen utensils or toilet. Apparently, it requires intense contact and friction, most commonly in the sensitive genital area.

The literature reports cases of HPV wart lesions in children.
TRUE When not related to child abuse, it is reported to occur by careless direct contact from the hand of an infected parent to the child’s skin.

HPV infection in pregnancy puts the embryo at high risk.
FALSE The virus has no teratogenic action. It may however infect the baby during delivery through an infected birth canal and may cause wart lesions in the baby’s throat. When prominent warts are seen within the vagina, a caesarean section is advised, in order to prevent direct contact. A pregnant woman with an abnormal Pap smear does not need to have a caesarean, she may be at risk but not the fetus and a caesarean will not anyway offer total protection.

Oral sex is a safe sexual practice as far as HPV transmission is concerned.
FALSE Warts in the mouth and pharynx are directly related to oral sex practice and it appears to be a common and serious problem as they may commonly develop into cancer. Saliva may have a protective effect against HPV, yet oral sex is a well documented mode of HPV transmission and significant related pathology.

Homosexual men are not at risk from HPV.
FALSE In recent years, HPV-related anal cancer is becoming a huge public health issue in homosexual populations. It is as common and serious problem as cervical cancer and we have not yet developed a screening program, as is the case with Pap smears and cervical cancer. Anal cancer risk obviously also affects women who practice anal sexual intercourse.
When infected by HPV, one will “carry” the virus indefinitely.
TRUE AND FALSE  In most of the cases, the virus will attach itself on the surface of the cervical cells, will independently multiply its genetic material (DNA) without affecting the DNA of its host cell. At some point, at 1-2 years the latest, the human body will mobilize its natural defense mechanisms and eradicate the virus. In a small percentage (up to 10%) of women, the virus (usually a high-risk strain) may persist, incorporate its DNA to the cervical cell DNA, and damage the host DNA (pre-cancerous lesion) and cause it to mutate (cancer).
A 40 year old lady presents with a pre-cancerous lesion seen on her Pap smear. That implies that she or her partner were recently infected by HPV.
TRUE AND FALSE  This could well be a recent infection, particularly if external warts co-exist along with the cervical lesion. Yet, it could also be associated with an old infection which gradually led to cellular damage and now presenting through the abnormal smear test.

The infection may raise issues many years after its initial transmission.
TRUE The natural history of the infection is anyway long. The time interval between the initial infection and the pre-cancerous lesion development is estimated to range between 7 and 15 years. Having sai that, in a small percentage of women this could be surprisingly short, up to 2 years after initiation of sexual activity and HPV infection. This is why the first Pap smear should be taken 18 months after the sexual activity initiation.

Younger women are primarily affected and considered to be high risk.
TRUE AND FALSE Infection is indeed more likely to occur to a 20 year old but she would be more likely to eradicate the virus within 1-2 years. Women older than 30 are less likely to be infected in the first place, but more susceptible to viral persistence and eventual serious lesion.

HPV infection will always lead to cervical cancer, unless medical intervention occurs.
FALSE The virus will infect the majority of women (life-time risk up to 80%) but only a slim percentage of those will eventually develop cancer. HPV virus is usually eradicated, and when it persists it is even then unlikely to develop into a serious lesion, let alone cancer. It is true though that medical intervention as in Pap smear population screening, significantly reduces the risk. In developing countries, where this is not available, cancer is much more common, reaching up to 80% of all global cases.
Women who smoke and are infected by HPV are more likely to later develop a serious pre-cancerous lesion.
TRUE When the virus persists, smokers carry up to twice the risk of developing serious lesion, than non-smoking women.
Viral persistence and detection in consecutive pap smears and colposcopies for over 2 years raise the risk for cancer development.
TRUE When the infection persists, it is probably a strain with high carcinogenic potential which has already managed to incorporate itself within the cellular DNA and it is now capable to activate abnormal mutations.
The incubation period between initial infection and lesion appearance on the skin or the cervix is just a few days.
FALSE It is estimated to range between 6 weeks and 8 months. External skin warts have been reported to occur up to 3 weeks after infection. A 3 month period is typically reported in textbooks.
A woman who has been given a Pap smear positive for HPV should inform her past and/or present partner.
TRUE We should bear in mind though that this viral infection is extremely common. If we take a picture today of the global population, a 10% of women will be found to be currently infected and we have already mentioned that the life-time infection risk is up to 80%. We should therefore avoid to blame or have feeling of guilt and remorse. Current or previous partners should be informed. Men are not at risk to develop cancer but they may carry the virus and infect a new partner, and they may after all develop skin warts. Incubation periods are as we said vague and even the doctor cannot safely guess the timing of infection. Just inform partners and be cool about it.
A young woman with HPV infection and an abnormal PAP smear test must have a surgical procedure to remove the lesion from her  cervix, before cancer develops.
FALSE We tend to avoid surgical intervention in young women and try to be conservative as long as it is safe. At her age, the lesion is anyway more likely to disappear spontaneously. Furthermore, we wish to avoid an operation that will destroy or remove part of her functioning cervix, which could later lead to fertility problems and preterm labour risk.
Medical treatment, suppositories, vaginal douches can be used to eradicate the virus.
FALSE There is no available medical treatment. This is exactly like the flu virus, there is no direct antiviral treatment, one can only prevent through vaccination. All available treatment modalities are destructive (diathermy, LASER) and there are also some topical remedies which fortify the local skin natural defenses. We do give emphasis to natural defense mechanisms, we advise the woman not to smoke, we treat any concurrent disease. We frequently tend to postpone treatment in order to allow time for natural defenses to mobilize and correct the cellular abnormalities.
The available vaccination is effective but is still experimental and its safety profile is not documented.
FALSE Its safety is well documented, its main side-effects being local irritation at the injection site (20-90% of cases) and transient fever (10-13%). No serious adverse effect has been reported and this not a new vaccination- several million doses of both available vaccines have already been administered worldwide.
The HPV vaccination constitutes a total prevention modality against cervical cancer, in other words, it protects 100%.
FALSE The vaccine covers against strains No 16 and 18, the most frequent high-risk strains. They are incriminated for 70% of cases of cervical cancer, hence the vaccination protection would be exactly at 70%. There is reliable evidence that demonstrates that other strains with similar structure are also covered. This cross-cover as a bonus will further raise the protection rate. The Pap smear screening program should nevertheless keep going. Once 16 and 18 are eradicated, other strains may tend to proliferate and cover the gap, the population screening should therefore not be discontinued.
There are two vaccinations in the market, equally effective.
TRUE Both have sufficient supporting evidence regarding their efficiency. The quadrivalent vaccine includes cover against the non-cancerous skin wart strains No 6 and 11.
Young girls, not yet sexually active, are the ideal candidates for vaccination.
TRUE When sexually active, one may suggest that HPV infection may have already occurred. The vaccination should anyhow take place early in life (before the age of 15) regardless of sexual activity, because it is more effective then, stimulating better immune response.

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