Q&A Discussion: HPV and Its Association with Cervical Cancer

Sarah Feldman MD, MPH is a Brigham and Women’s Hospital expert in gynecologic oncology whose clinical focus centers around HPV screening and prevention.

What is HPV, and how does it relate to cancer risks in both men and women?

HPV, or Human Papillomavirus, is a common sexually transmitted virus. There are 14 types associated with cancers of the lower genital tract, including the cervix, vagina, vulva, anus, and penis, as well as oral-pharyngeal cancers. The most aggressive types are HPV 16 and 18, but all 14 high and intermediate-risk types are linked to cervical cancer. HPV is transmitted through intimate skin-to-skin contact, and up to 80% of both men and women in the U.S. may test positive for it. Condoms provide partial protection as the virus can exist on both external and internal genital skin. But people should definitely be using condoms to protect from other sexually transmitted diseases. Most HPV infections, however, go away on their own, and when dormant, the virus does not affect cancer risk, but it remains contagious even when not detected in tests.

There is ongoing research regarding HPV inactivity. It is generally believed that once acquired, HPV becomes dormant for a period ranging from months to years before potentially reactivating. While it is not assumed to exist indefinitely in the body, further research is needed to understand the reasons why it can reactivate in the body.

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What percentage of cervical cancers are caused by HPV?

Close to 100% of cervical cancers are associated with HPV. HPV is so strongly associated with cervical cancer that HPV infection activity (when you test positive, and the infection is active) has become a new way to screen for cervical cancer risk. We’re not screening for cancer when we take an HPV test from the cervix, we’re screening for whether or not the person is infected with one of these high or intermediate-risk viruses. If you persistently test positive for several years, you’re at risk of developing a pre-cancer and your cancer risk is elevated relative to the baseline population.

What does the HPV vaccine protect against, and does it guarantee immunity from all cancer-causing strains?

The Quadrivalent vaccine protects against HPV 16 and 18, responsible for 70% of high-grade dysplasia or cancer. The 9-Valent vaccine provides protection against 90% of cervical cancer associated with HPV. However, individuals vaccinated may still be at risk for the remaining 10% of cancer attributed to other strains.

What steps should someone take upon discovering they have HPV?

HPV is a screening test. When a person tests positive it means they are at increased risk of a disease, but they still need diagnostic testing with possible biopsy to determine management. Women who test positive for a high-risk HPV strain should follow their doctor's advice for next steps. Specific guidelines exist based on age, pap test results, HPV type and immune status. Some patients may be evaluated by colposcopy (a procedure to closely examine your cervix, vagina and vulva for signs of disease) or treatment may be necessary depending on a review of a patient’s current and prior results. Unfortunately, we don’t have a way to routinely test male patients. However, men are at risk for oropharyngeal, anal and penile cancers, and should contact their doctors for any symptoms in those areas.

Have we observed any downward trends in cervical cancer development since the introduction of the HPV vaccine?

Absolutely! Vaccination rates play a significant role in cervical cancer trends. In countries with widespread vaccination, such as Australia and England, there has been a significant decrease in cervical cancer rates, especially among those vaccinated before the onset of sexual activity, ideally by age 15. The vaccine's effectiveness is highest when administered at ages 9 to 12. Among women who are vaccinated between their late teens and 26, there’s also a decrease in cancer rates, although it’s not as low as for the people who are vaccinated before the onset of sexual activity. Also, in Australia where they’ve been vaccinating young people for many years and they have a very effective vaccine program, they’ve seen an almost complete eradication of genital warts in that age group.

In the United States, states with higher vaccination rates, such as Massachusetts, tend to observe lower cervical cancer rates. However, external factors, such as the COVID pandemic, may influence delayed healthcare, impacting cancer rates.

How is cervical cancer treated, and are there specific approaches at Dana-Farber Brigham Cancer Center?

Cervical cancer is treated by specialized gynecologic oncology surgeons, medical oncologists and radiation oncologists. Treatment approaches vary but often involve a combination of surgery, radiation, chemotherapy, or precision medicine. Dana-Farber Brigham Cancer Center offers fertility-sparing treatments as an advantage, meaning that many of our treatments do not affect long-term ability to have children, which is what a lot of people are worried about.

What research is being conducted at Brigham and Women’s Hospital on HPV or cervical cancer?

Research at Brigham and Women’s Hospital focuses on improving access to screening, studying real-life screening practices, and addressing disparities in vaccination, screening, and care for patients with cervical cancer. The purpose of this research is to ensure that all people who need it are getting screened and are screened accurately.

What else is crucial for people to know about preventing cervical cancer?

Cervical cancer is preventable through a combination of early vaccination, screening, and managing abnormalities. Regular screening is essential, and abnormal results should not be ignored. Vaccination in childhood is more effective than in older women, emphasizing the importance of preventive measures early in life. And if you already got the vaccine when you were younger, you do not need a booster.

The last thing I’ll say is that there’s not that much preventive care as women that we have to do in our 20’s or 30’s. This is THE THING that you need to start early on to prevent having problems when you’re older. If this is the one thing you do in your 20’s, do it: get the vaccine, get screened and follow up with any abnormalities.

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