Crossroads Magazine
Although cervical cancer incidence and mortality rates have declined almost 50% over the last 30 years in the United States, the disease remains a serious threat to women. Annually, more than 9,700 new cases of cervical cancer are diagnosed, and nearly 4,000 deaths are attributed to the disease. Worldwide, cervical cancer is the second most common cancer in women, with 470,000 new cases each year and 233,000 deaths. However, when detected early, cervical cancer has an extremely successful cure rate.
While cervical cancer continues to threaten women worldwide, significant progress is being made in the prevention and treatment of the disease. One pharmaceutical company has recently introduced a vaccine for the disease, and physicians at the UAB Comprehensive Cancer Center are beginning to use robot-assisted surgery to more effectively treat their patients. The future of cervical cancer treatment and prevention is becoming brighter.
Cervical Cancer Vaccine
An essential strategy to reduce the risk of cervical cancer is screening through a Pap test. In recent years, researchers have identified human papilloma virus (HPV) as the predominant cause of cervical cancer. Nearly 6.2 million Americans become infected with HPV each year, and more than half of all sexually active men and women will become infected at some point in their lives. While there are more than 200 types of HPV, most strains are harmless, and most infections clear up spontaneously. There are other “high-risk” types that can lead to cervical cancer if left untreated. Of particular concern are the types HPV 16 and 18, which account for 70 to 75% of all cervical cancers.
In June 2006, the Food and Drug Administration (FDA) approved the first-ever vaccine proven to prevent cervical cancer. Tests in more than 17,000 girls and women have shown that the vaccine, Gardasil®, is nearly 100% effective in blocking cervical cancers caused by HPV. Gardasil® prevents four strains of HPV, including HPV 16 and 18. The other two strains are responsible for the majority of cases of genital warts. Also in June, an advisory committee for the Centers for Disease Control and Prevention recommended the vaccine be added to the schedule of suggested childhood and adolescent vaccinations.
While Gardasil® has been hailed as a major public health breakthrough, there are some concerns and misperceptions about the vaccine. “Gardasil® is a monumental scientific achievement in terms of addressing cervical cancer, but there are some significant unanswered questions that need to be examined and addressed carefully,” says UAB gynecologic oncologist and Cancer Center Associate Scientist, Warner Huh, M.D.
The vaccine was approved for girls and women ages nine to 26. It is still unknown what the activity of the vaccine is among older women. Because the vaccine is ineffective once the virus is already present, it is most useful when given to younger girls. The prospect of a vaccine for a sexually transmitted disease for an age group of children not sexually active is concerning for some parents. Various conservative religious groups have expressed that the vaccine is unnecessary when children are taught to abstain from pre-marital sex. Dr. Huh disagrees, saying, “The biggest misperception is that the vaccine is going to promote sexual promiscuity among young girls, but that has been shown not to be the case.”
Another concern regarding the vaccine is that it will lead women to discontinue cervical cancer screenings. According to Dr. Huh, despite the effectiveness of the vaccine, women should continue to get pap smears. About one-quarter of cervical cancer cases are caused by viruses not blocked by the vaccine. “It is important for women who receive the vaccine to recognize that pap smears are still important, and that the vaccine does not protect against all high-risk HPV types,” he says. He emphasizes that the lasting effects of the vaccine are still being investigated, including the role of other HPV strains after those blocked by the vaccine are eradicated.
Other questions abound as to who will administer the vaccine, whether it should fall upon OB-GYNs, pediatricians or family practice physicians, as well as who will cover the costs for the required three shots. Most importantly, Dr. Huh says, is that people realize this vaccine is not the end of cervical cancer. “We are not going to eradicate cancer in this country within a year of administering this vaccine. People need to be patient,” he says.
The DaVinci® Robot
For some cervical cancer patients, the Cancer Center is utilizing the latest in minimally invasive surgery to make their treatment and recovery better. Dr. Huh, along with Cancer Center Scientist and fellow gynecologic oncologist Larry Kilgore, M.D., are using the daVinci® surgical system to perform radical hysterectomies for women with early invasive cervical cancer. Drs. Huh and Kilgore are the only two physicians in Alabama certified to utilize this state-of-the-art technology for this procedure.
The robot-assisted hysterectomy provides significantly better results than the traditional hysterectomy. Conventionally, women have received radical hysterectomies through large incisions in the abdomen. With the da Vinci® robot, the surgery is performed with small punctures instead of an incision. The surgeon operates while seated a few feet away from the patient at a console and looking through a viewfinder. The viewfinder provides the surgeon a unique three-dimensional image not afforded by traditional surgeries, allowing for greater precision and accuracy.
The surgeon’s hands are naturally positioned with his or her fingers grasping the controls below the display. Movements are transferred real-time to the surgical instruments inside the patient. The da Vinci® robot cannot be programmed, nor can it make decisions on its own to move in any way or perform any type of surgical maneuver.
Sarah Thomas, a cervical cancer patient who was treated at the Center, knows the benefits of the da Vinci® surgery firsthand. “There were not a lot of options to treating my cervical cancer,” says Ms. Thomas. “When Dr. Huh explained the da Vinci® surgery to me, I knew I definitely wanted to try it.” Ms. Thomas was one of the first to undergo a da Vinci® radical hysterectomy in June and could not be happier with her results. “I could tell a difference in the way I felt from the minute I woke up,” she says. “To my surprise, I was able to get out of bed and walk around and take a shower pretty comfortably within the first 24 hours.”
One of the major benefits to patients receiving the robot-assisted surgery is shorter recovery time. After receiving a radical hysterectomy using this technology, recovery time is shortened from two to three months to as little as two or three weeks. Less than two weeks after her surgery Ms. Thomas returned to work and was able to reassume her swimming and walking routine. Da Vinci® surgery also provides for less pain, less bleeding and less scarring.
Surgeons utilizing the da Vinci® robot also receive a great benefit – increased dexterity. “In a standard laparoscopy, the instruments are largely rigid and fixed; it’s like operating with chopsticks,” says Dr. Huh. “With da Vinci® surgery, the tips of the instruments bend similar to a wrist. There is actually greater flexibility than a human wrist.” These laparoscopic instruments essentially miniaturize the surgeon’s hands and place them inside the patient’s body, allowing more freedom of movement and providing the surgeon with an immersive surgical experience. The abdomen can be more thoroughly explored – nerves and blood vessels are easily identified and bleeding can be controlled with precision not afforded by traditional surgery.
While the surgery was a success for Ms. Thomas, Dr. Huh wants patients to understand that not every patient is a candidate for the procedure. According to Dr. Huh, the device is most beneficial in patients with cervical cancer and is not necessarily a replacement for standard laparoscopy. “The da Vinci® robot combines the benefits of minimally invasive surgery and open surgery,” says Dr. Huh. “It opens windows of opportunity for minimally invasive surgery that we’ve never had before.”