CLINICAL OBSTETRICS AND GYNECOLOGY Volume 57, Number 2, 239–240 r 2014, Lippincott Williams & Wilkins
Preventing Morbidity and Mortality From Cervical Cancer NEAL M. LONKY, MD, MPH*w *Southern California Permanente Medical Group, Department of Obstetrics and Gynecology, Kaiser Permanente, Anaheim; and w Department of Obstetrics and Gynecology, University of California School of Medicine, Irvine, CA
Foreword
It is my pleasure and privilege to work as a guest editor for this symposium. I have invited experts in the field to assist in helping the readership navigate a fairly complex set of algorithms and truly linking our existing knowledge base with the rationale behind the use of the vast screening, triage, and treatment technologies and decisions at our disposal. My aim for this symposium was to analyze and integrate the excellent body of work that has been conducted in the last decade regarding the etiology, natural history, management, and therapeutic options used in preventing morbidity and mortality from invasive cervical cancer. The recent published guidelines by many societies and authorities, including the American Society of Colposcopy and Cervical Pathology, sought to provide a guidepost for the average patient in the average population, recognizing that certain very high-risk groups might require further evidence-based decisions. We attempted to address some of the special populations, including those at the extremes of age (adolescents, elderly) and underserved patients with health care disparities. In chapter 1, I lead a section on the Public Health approaches, opportunities, and challenges of effective cervical cancer prevention. It highlights the focus on the histopathologic endpoint of CIN 3+ as our treatable target ‘‘true cervical cancer precursor’’ because therapeutically addressing earlier stages of CIN is problematic. Existing treatments for CIN are predominantly ablative or surgical, with potential sequelae, especially reproductive harms to young women. Thus, the new guidelines, balancing benefits with harms, promote a more conservative ‘‘wait and see’’ approach in reproductive age women, the population most likely to experience an abnormal
Correspondence: Neal M. Lonky, MD, MPH, Kaiser Permanente, Anaheim-Kraemer Office Building 2, 3430 E. La Palma Avenue, Anaheim, CA 92806. E-mail: [email protected] Histologics LLC: Director, Inventor and Inventor: Speculoscopy. CLINICAL OBSTETRICS AND GYNECOLOGY
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VOLUME 57
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NUMBER 2
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Foreword
screening test and harbor CIN that is not CIN 3+ . Although part of a reversible neoplastic continuum with a viral precursor (human papilloma virus), we still lack a reliable, affordable, and accessible minimally invasive therapy. The chapter on primary prevention reviews the biological basis for neoplastic transformation, understood to be linked to genomic alteration and expression following HPV infection and insinuation. The effect of behavioral, pharmacological, and immunologic (vaccination strategies) interventions in reducing the risk of neoplastic emergence (immortalization) and ultimate progression toward cancer is the focus. The chapter on secondary prevention reviews our existing armamentarium in screening, triage, and management (including observation of natural changes, which lead to regression versus therapy to ablate, excise, or treat neoplastic lesions to effect true regression or eradication of risk). It highlights findings from pivotal trials and guidelines published and promoted by experts in the field. It is the core of what we are currently doing to utilize screening, triage, and treatment resources in an era wherein the value of health care intervention is weighed, both medically and financially. The chapter on tertiary prevention highlights the current and future options in managing women who harbor early or advanced cervical cancer. The surgical and chemotherapeutic options, as well as immunotherapeutic trials are presented, and offer hope that even if women do escape the vast safety net, and develop cancer, there are effective therapies that exist and are emerging that will prolong life with the maximum quality of life in mind in survivors. It has been my honor and privilege to provide this body of work. I was the guest
www.clinicalobgyn.com
editor of a similar symposium published in 2002, and although the guidelines and focus has changed somewhat, and another decade of scientific observation and trials has led us to respect the potential harms of early and aggressive therapy, we must understand that the limitations of therapies for young women who become infected with HPV is holding back true secondary prevention. Primary prevention also suffers from a lack of knowledge, cultural beliefs, affordability, or effective public health measures in effectively vaccinating the population, especially in the United States. If and when we have a minimally invasive and safe means to eradicate early HPV infection or its genomic insinuation or expression toward malignant transformation, we can leverage the cytologic, biomarker, virologic, visual-based, and biophysical screening tests that have increased our ability to detect ‘‘risk’’ by means of virus, viral-associated proteins or DNA markers, or lesion emergence and provide medical or minor surgical options over more destructive options. Once we lower the prevalence through vaccination and other primary preventive means, and utilize early minimally invasive therapies, the prevention of cervical cancer is in our grasp, as it evolved for other infectious disease–related morbid diseases, such as tuberculosis.
Acknowledgments The author would like to acknowledge all of the authors of this symposium for their contribution to the symposium and thank them for their dedication to women’s health.
Preventing Morbidity and Mortality From Cervical Cancer NEAL M. LONKY, MD, MPH*w *Southern California Permanente Medical Group, Department of Obstetrics and Gynecology, Kaiser Permanente, Anaheim; and w Department of Obstetrics and Gynecology, University of California School of Medicine, Irvine, CA
Foreword
It is my pleasure and privilege to work as a guest editor for this symposium. I have invited experts in the field to assist in helping the readership navigate a fairly complex set of algorithms and truly linking our existing knowledge base with the rationale behind the use of the vast screening, triage, and treatment technologies and decisions at our disposal. My aim for this symposium was to analyze and integrate the excellent body of work that has been conducted in the last decade regarding the etiology, natural history, management, and therapeutic options used in preventing morbidity and mortality from invasive cervical cancer. The recent published guidelines by many societies and authorities, including the American Society of Colposcopy and Cervical Pathology, sought to provide a guidepost for the average patient in the average population, recognizing that certain very high-risk groups might require further evidence-based decisions. We attempted to address some of the special populations, including those at the extremes of age (adolescents, elderly) and underserved patients with health care disparities. In chapter 1, I lead a section on the Public Health approaches, opportunities, and challenges of effective cervical cancer prevention. It highlights the focus on the histopathologic endpoint of CIN 3+ as our treatable target ‘‘true cervical cancer precursor’’ because therapeutically addressing earlier stages of CIN is problematic. Existing treatments for CIN are predominantly ablative or surgical, with potential sequelae, especially reproductive harms to young women. Thus, the new guidelines, balancing benefits with harms, promote a more conservative ‘‘wait and see’’ approach in reproductive age women, the population most likely to experience an abnormal
Correspondence: Neal M. Lonky, MD, MPH, Kaiser Permanente, Anaheim-Kraemer Office Building 2, 3430 E. La Palma Avenue, Anaheim, CA 92806. E-mail: [email protected] Histologics LLC: Director, Inventor and Inventor: Speculoscopy. CLINICAL OBSTETRICS AND GYNECOLOGY
/
VOLUME 57
/
NUMBER 2
/
JUNE 2014
www.clinicalobgyn.com | 239
240
Foreword
screening test and harbor CIN that is not CIN 3+ . Although part of a reversible neoplastic continuum with a viral precursor (human papilloma virus), we still lack a reliable, affordable, and accessible minimally invasive therapy. The chapter on primary prevention reviews the biological basis for neoplastic transformation, understood to be linked to genomic alteration and expression following HPV infection and insinuation. The effect of behavioral, pharmacological, and immunologic (vaccination strategies) interventions in reducing the risk of neoplastic emergence (immortalization) and ultimate progression toward cancer is the focus. The chapter on secondary prevention reviews our existing armamentarium in screening, triage, and management (including observation of natural changes, which lead to regression versus therapy to ablate, excise, or treat neoplastic lesions to effect true regression or eradication of risk). It highlights findings from pivotal trials and guidelines published and promoted by experts in the field. It is the core of what we are currently doing to utilize screening, triage, and treatment resources in an era wherein the value of health care intervention is weighed, both medically and financially. The chapter on tertiary prevention highlights the current and future options in managing women who harbor early or advanced cervical cancer. The surgical and chemotherapeutic options, as well as immunotherapeutic trials are presented, and offer hope that even if women do escape the vast safety net, and develop cancer, there are effective therapies that exist and are emerging that will prolong life with the maximum quality of life in mind in survivors. It has been my honor and privilege to provide this body of work. I was the guest
www.clinicalobgyn.com
editor of a similar symposium published in 2002, and although the guidelines and focus has changed somewhat, and another decade of scientific observation and trials has led us to respect the potential harms of early and aggressive therapy, we must understand that the limitations of therapies for young women who become infected with HPV is holding back true secondary prevention. Primary prevention also suffers from a lack of knowledge, cultural beliefs, affordability, or effective public health measures in effectively vaccinating the population, especially in the United States. If and when we have a minimally invasive and safe means to eradicate early HPV infection or its genomic insinuation or expression toward malignant transformation, we can leverage the cytologic, biomarker, virologic, visual-based, and biophysical screening tests that have increased our ability to detect ‘‘risk’’ by means of virus, viral-associated proteins or DNA markers, or lesion emergence and provide medical or minor surgical options over more destructive options. Once we lower the prevalence through vaccination and other primary preventive means, and utilize early minimally invasive therapies, the prevention of cervical cancer is in our grasp, as it evolved for other infectious disease–related morbid diseases, such as tuberculosis.
Acknowledgments The author would like to acknowledge all of the authors of this symposium for their contribution to the symposium and thank them for their dedication to women’s health.
