Dr Miriam Cremer is founder of Basic Health International, which exists to eliminate cervical cancer on a global level through cutting edge research for the prevention and treatment of cervical cancer in low resource settings. Dr. Cremer, founded Basic Health after seeing first hand the devastating impact of this devastating yet preventable cancer can have on women.
Georgie Kovacs: What is cervical cancer and how does one get it?
Dr Miriam Cremer: A precursor to cervical cancer is an infection with human papilloma virus (HPV), which is a combination of many different viruses. There are 13 to 14 high-risk HPV types that persist and lead to invasive cancer.
Many people will get HPV. In fact, there was a study in Syracuse where 77% of college age women who are sexually active, have HPV. Most of the time, it clears on its own, yet we don't have excellent predictors of when it's going to clear when it's going to go away. There are some pesky high-risk types, which persist and lead to pre-cancer and then lead to cancer.
It's very rare to find a cancer where you have a precursor, you have a vaccine for it, and you have an organ you can get at and treat right away. Why is it that women are dying of cervical cancer?
HPV leads to persistent infections and can lead to abnormal results. The sad thing is, in the United States women of color and foreign born women are disproportionately impacted. It's all about access.
Georgie Kovacs: I know that we're encouraged at least in the United States to get an annual pap smear. Does this screen for HPV or is an additional test required at the exam?
Dr Miriam Cremer: It's a really good question, but I'm going to take you before your screening. There's an indication for a vaccine most importantly, prior to sexual initiation and thus potential HPV exposure. Anybody who has sex is exposed to high risk HPV types.
The vaccine indication is ages nine through 45, but when it works the best is when you can amount immune response against these specific viruses. We have a lot of data that this vaccine works really well, that it prevents not only cervical cancer, but it also prevents head and neck cancers. The side effects are side effects with any vaccine.
Ideally, girls get vaccinated prior to age 15.
Georgie Kovacs: Once a famous actress began raising questions about vaccines, many are choosing not to vaccinate their children. Can you provide further guidance on this HPV vaccine to address such concerns?
Dr Miriam Cremer: So I'm going to give you a disclosure. First, I do speak on behalf of Merck, but I believe so much in this vaccine that I gave talks on it. Even if I didn't speak for Merck or if we had another vaccine, I really believe in it because it is a very rare thing that you have a cancer that you have one risk factor for, and if you can prevent that risk factor, you can prevent that cancer.
This vaccine has been around since the early two thousands. We have a Nordic cohort that is about 10 years ahead. Vaccination programs in the U.S. started pretty actively around 2003, but the Nordic cohort was before that, and large randomized trials were done that showed that it prevents the cancers that are in the vaccine. So for the certain high risk types, it is very effective in preventing these cancer types.
Georgie Kovacs: What are the HPV vaccine side effects that people are so concerned about?
Dr Miriam Cremer: There are hundreds and thousands of HPV vaccine doses that have been given. It has been around longer than the iPhone and we have good safety data. The side effects are similar to those that would happen within th general population. The adverse events that people worry about - autism seizures, inability to walk parallel paralysis - those things are the same in a vaccinated and an unvaccinated population, and they have been for the past decade.
Georgie Kovacs: Is it the HPV vaccine and annual pap smear that is causing cervical cancer rates to decline?
Dr Miriam Cremer: The cervical cancer rates, for sure, are declining. Australia has a primary vaccination program. They've decreased endpoints of disease, which are the pre-cancers, which is pretty astounding.
The pap smear was something that started in 1948, and it involves taking a little brush of cells off your cervix that go on a slide. When reading the slide, if it looks abnormal, you come back and have a cervical biopsy. That strategy was hugely effective in the past 50 years of decreasing rates of cervical cancer in the U.S.
The standard of care right now in the U.S. is something called co-testing. So you take a pap smear and at the same time, you can test to see if a woman is infected with HPV.
A pap smear, we call it cytology, is not as good of a test as an HPV test, and it will probably be obsolete within the next 10 years. If you have negative HPV tests, further testing is required every five years or every three years.
Since 2009, we have said, you're going to do the cytology tests and the HPV test at the same time. The direction I think we're going to move to is primary HPV testing. Okay. And I guess I would say one caveat with it. If you have younger listeners, anybody per some guidelines, under 30 and some guidelines, under 25. So many people in that cohort have infection with HPV and there's not a lot of high grade pre-cancers and cancers in that group.
Georgie Kovacs: Let's say you're in the unfortunate situation of having cervical cancer. What does that mean and how treatable is it?
Dr Miriam Cremer: In the U.S., most people will be in a situation that they have an abnormal pap smear and that they are told that they have pre-cancer. Many that have had an abnormal pap smear must get a colposcopy, which means we look at your cervix under a microscope and take a little piece of tissue. It’s a punch biopsy that you take with the cervix. It's a little bit uncomfortable, but it's also scary. You put your legs in the stirrups, put some vinegar on your cervix, look with a magnifying glass and then taking samples, sending them to pathology. If those are abnormal, we treat with excising your cervix, which can make it shorter, where it may be less likely to be able to carry a pregnancy to full term.
We're concerned about whether pre-cancers are going to go to cancer, but many of those also clear on their own. In young women, they clear much more often. So we're looking at risk - your risk of pain and suffering of having to go in for all those tests, when it might go away on its own, or you might have an invasive procedure, that's going to affect obstetrical outcomes.
It's highest in minority populations because they might not interface the healthcare system as much. So we have to do a better job in the healthcare system to make people feel welcome, to come, make it accessible, make those tests affordable, and the followup affordable, because what good is a test going to do if you can't get the proper follow-up?
It's women that don't get those screening tests that wind up with cervical cancer. Other risk factors are you smoke and you have HIV. Immunocompromised women may be more likely to have cervical pre-cancers and cancers.
The good news about pre-cancers is they're always treatable, and we have really good tools in the U.S. to treat them, and you can still keep your uterus, so you can still have babies. It's an outpatient procedure. You don't need chemotherapy, you don't need radiation.
The time you go from HPV infection to pre-cancer to cancer is years. So there's only time to find that and treat it. Thus, nobody should wind up in that unfortunate place of getting cancer. It's just unacceptable, right? With all these tools that we have, how can anybody wind up with invasive cancer?
Georgie Kovacs: Let’s talk about how STDs impact fertility.
Dr Miriam Cremer: I'll start with, there's no shame in an STD. It's so common, that every time I'm in my office, I diagnose somebody with an STD. It’s just not generally coffee table conversation.
In young women, the most common is HPV, which can lead to cervical cancer and pre-cancer and can also lead to genital warts.
Genital warts are common, uncomfortable and preventable with the vaccine. It's a lower risk type that won't lead to cancer. So if you have genital warts, it doesn't mean you have pre-cancer.
Other STDs are chlamydia, gonorrhea, and trichomonas. Sometimes you don't feel it. You know, there's no vaginal discharge. To diagnose, I just take a swab, send it to the lab and I find out we can give them some antibiotics and it goes away. But if it doesn't go away, you can get inflammation, scarring and difficulty getting pregnant scarring where in the uterus and the tubes, like endometriosis.
The importance of an annual exam for young women is to have those STI screenings.
Another common infection, which sadly, we don't have a cure for, is herpes. We have some great suppression medicines for it that you can take, however.
Condoms help, but they're not a hundred percent effective. Thus, you and your partner can get screened before you decide to have sex without condoms.
Georgie Kovacs: The HPV vaccine is for men and women. And so that's another screening women can do is ask their partner if they've had the vaccine. Right?
Dr Miriam Cremer: Yes. I can tell you uptake in the U.S. Is not great. I was on the committee making the new cervical cancer screening guidelines and we can't use any like vaccinated versus unvaccinated changing how you screen them because there's not enough data because they're not people being vaccinated. So our vaccination, we could do so much better in the U.S. Most of the time we're recommending vaccinations. And before seventh grade, I think it is. At that point, if your kid's not in sports, you're not doing all those physicals. So where's our touchpoint for girls between 13?
Georgie Kovacs: So is there anything else about cervical cancer that maybe I didn't ask a question about?
Dr Miriam Cremer: Primary prevention is key. Get vaccinated. Get your screening, particularly if you are over 30, make sure that screening includes an HPV test.
People move around a lot, so it's not a bad idea to know your status. And the key questions I think to know about yourself is, was I HPV positive or negative, but if you really want to be savvy, did I have HPV 16 or 18? If you move to another health care center, you can share that important information.
Georgie Kovacs: Please expand on HPV Types 16 and 18.
Dr Miriam Cremer: Those are the most high risk HPV, where Type 16 is the most high-risk (60% of cervical cancers are caused by this type). HPV Type 18 causes another 20% of cervical cancer cases).
Know your history because with these new guidelines, we're going to have a risk-based management. This means that I can tell you, “Your risk of developing invasive cancer is this percent. I think you should have a colposcopy.”
Georgie Kovacs: How can patients get access to care?
Dr Miriam Cremer: The United States, patients can access federally qualified health centers, FQHC. They have phenomenal primary care. It does not matter whether you have any health care coverage or your immigration status. Planned Parenthood is also a fantastic place to go. We, as providers, need to be accessible to everybody.
Two at-home, or self-sampling, HPV tests that are already approved by the FDA for just the HPV test, without the pap smear. What that means is that a woman could just take a swab, put it in her vagina and send it off and get the results. So that's super cool because if you're looking at a population-based screening.
Georgie Kovacs: Is this an at home HPV test and is it available yet?
Dr Miriam Cremer: It is not yet FDA approved, but it's coming. I anticipate that it will be soon. That will be the future of screening. Roche’s cobas and BD’s Onclarity will be the first ones.
Kate Colligan: Self sampling could be something that is affordable and allow for increased access. BHI (Basic Health International) led research for transgender men, where you're in a situation where maybe the medical system is not fond of your choices, yet you still need to have cervical cancer screening. Anybody with a cervix needs to have screening and they need to have safe places to get that screening. Self-sampling is pretty exciting for transgender me because it's really private. And if it's negative, you can be really reassured.
Georgie Kovacs: What is your greatest hope for women's health?
Dr Miriam Cremer: Nobody should die of a preventable disease. You know, it's something that's plagued me since watching that woman die needlessly in El Salvador, you know, we have all of these tools like the WHO this year has called for elimination of cervical cancer. It can be done within my lifetime. Like nobody should die of that. And everybody should have had the access to healthcare. It's a basic human right.
About Fempower Health and Its Founder
Georgie is the founder and host of the Fempower Health podcast, a top 10 women’s health podcast with 5 stars on Apple. She is an advocate leveraging her 20+ years in healthcare and personal fertility journey to transform women’s healthcare, answering your health questions. She brings on top experts in women’s health with the aim of educating women about their bodies to have more empowered (and speedy) health journeys.
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