Saturday, March 20, 2010

How accurate is the conventional method of screening for Cervical Cancer?

This post is written based upon the observation and personal experience of the author, and not influenced by means of payment or any other form of remuneration by any pharmaceutical companies or parties.
With the discovery of Pap smear more than 50 years ago, death due to cervical cancer has been reduce significantly throughout the years worldwide. With the production of first ever Cancer vaccine back in February 27,2006, it marked  a milestone in the history of medicine where personally I felt its significance is in par with the landing of the first man on moon.
With the second vaccine produced by pharmaceutical giant, GSK, it added on to the arsenal at our disposal in the fight against cervical cancer. However, despite these development over the years, even with the marked reduction of mortality, it makes no difference to the family member and patients who was diagnosed with this killer disease.
Somehow, with the presence of these vaccines, some individuals developed this false sense of security that their immunity against cervical cancer last forever, in actual fact false. These vaccines prevent future infection of HPV(Human Papilloma Virus), but does not cure the already existing HPV.
Though vaccinated, one still needs to be screened annually. Last year alone, I had three patients who has sisters who never missed any of their annual Pap Smear, and each time was told to be normal, unfortunately, 5-6 month later, died of cervical cancer.
Despite the marked reduction of occurrence over the years, it makes no difference to these family members and victims who had succumbed to this killer disease which is currently ranked number 2 as the cause of death among women.
In my previous post, I had wrote on why Cervarix is far superior to Gardasil.

Deciding on getting the vaccination done is by far one of the best decision made in a woman's life. If you have decided to totally avoid from contracting this killer disease, vaccination MUST be followed up with annual Pap smear.
Unfortunately, the conventional Pap smear which most clinics perform have a high incidence of false negative. (when a patient have an early changes in the endocervix, which conventional Pap smear fails to detect, and hence its reports comes back as normal)
Such error is tragic to the victim and their family member.
Error occurs especially when cervical carcinoma arises from the inner part of the cervix, where conventional Pap smear's methodology of sampling is relatively poor, hence yields an inaccurate result, which gives a false sense of security to the unfortunate patient. This form of cervical carcinoma is called cervical adenocarcinoma.

While sampling from carcinoma that arises from the ectocervix as illustrated on the diagram above, cancer arising from the endocervix is not easily detectable.

A conventional Pap Smear kit.

The sampling is done using a wooden spatula which is then smeared on a glass slide, which then "fixed" with a chemical called cytospray which then is then looked at under a light microscope by a pathologist.
This method is proved to have high incidence of false negative due to several factors:-
1.majority of cells not collected
2.Non- representative transfer
3.Clumping and overlapping of cells
4.Obscuring materials
Hence since 1996, an improvised version that lessen the false negatives up to 30% was introduced. It is called Thin Prep Pap Smear.

The Thin Prep Pap Test is a liquid-based pap test that employs a fluid transport medium to preserve cells and an automated process to eliminate debris and distribute a representative portion of cells on a slide in a uniform, even layer. A Thin Prep Pap Test slide is clearer, easier to read, and minimizes obscuring blood, mucus, and non-diagnostic debris, enabling increased accuracy for both manual assessment and computerized assessment of the cells. The Thin Prep Pap Test process improves the quality of the sample, preparing a slide that is more appropriate for diagnostic review.

The additional advantage of Thin Prep Pap Smear is that if there exist any abnormality in the cytology report, the same sample can be sent for HPV DNA testing to determine the subtype of HPV(Human Papilloma Virus), or for further test for sexual transmitted diseases.

Hence ladies, with the availability of an improvised Pap Smear, insist upon it to your doctor that you want this method instead of the conventional Pap smear.

Friday, March 19, 2010

Cervical Cancer Vaccine...

I have written several post on Cervical Cancer in my blog as I felt the need to create an awareness among the public on how rampant it is, being ranked number 2 killer among causes of mortality among women in Malaysia.
However, I felt the level of awareness is still very limited, and despite our effort of lowering the price down to RM165 per dose(there are some clinics that charge RM500 per dose), very few number of women showed interest.
With the availability of Cervarix, which personally I think is far superior compared to Gardasil, women now have a choice, on which to chose from. Unlike several years ago when Gardasil was first launch, being the only cancer vaccine available, the price wasn't affordable to the masses. Unfortunately, despite such drastic price reduction purely for the purpose of providing an excess towards a more affordable health care, many women still remain ignorant.

Cervarix even though being advertised as being a bivalent vaccine, (provides immunity to two subtypes of HPV that causes Cervical cancer), latest date shown that it provides cross protection against three other subtypes,hence making it actually a pentavalent vaccine!)

Initially being advertised that it provides protection against HPV type 16, and type 18, now data shown that it provides additional 3 subtypes, that are type 31, 33, and 45. (the top 5 most oncogenic types)
Unlike Gardasil, it uses an adjuvant in its formulation, AsO4, which gives a rapid and a prolonged immunity against these viruses.

As you can see, cervical cancer being ranked second amongst all cancer as well as overall that affects women.

It's prevalence is the most between the age group of 30-60 years old. Note that quite a significant figure is from the age group of 70s and more.

Hence, since the recommended period of injection for Cervarix is between the age of 10-45, I would still recommend injection amongst the age group exceeding 45 years old.

Cancer does not recognized age of its victim. It spreads and kills irrespective of age.

In Klinik Wan dan Keluarga, we council patient's on importance of getting vaccinated.

Do not procrastinate anymore. While being a revolutionary drug that made a mark in the milestone in the field of medicine, it still receives poor response, unfortunately.

So,ladies, get your jab right away. Never think that it can never happen to you.

I bet Anita Mui and Farrah Fawcett never thought they would contract cervical cancer, until when it's too late.

Tuesday, March 9, 2010

New Data on Cervarix

**This post is written based upon the author's personal view, and not sponsored nor received any form of incentives by the respected pharmaceutical company.**

It has been known to be of utmost significance, at par in my opinion to the landing of the first human on the moon  back in 1969 as in the field of medicine, the discovery of the first ever vaccine against cancer. February 27 2006 marked as a milestone in the history of medicine when the first ever Cervical Cancer Vaccine, Gardasil, was launched. It was advertised as a tetravalent vaccine, which means it provides immunity against 4 subgroups of HPV virus,(Human Papilloma Virus)subunit 6,11,16, and 18. 
There are over 100 subgroups of HPV identified and each is given a number. 
Generally, HPV virus is divided into oncogenic and non oncogenic groups. HPV is transmitted through sexual contact. Based on a study conducted locally, more than 70% of women would have experienced sexual intercourse before the age of 25. While 70% of HPV resolves by the first year and 90% resolves by the second year, the other 10% stays within the skin and lays dormant for years. It does not travel within the bloodstream, hence undetectable by blood investigations. When Gardasil was launch, it was accepted worldwide, but not without controversy.Some school of thoughts claimed with the vaccine it gives a false sense of security that encourage sexual promiscuity amongst young women. 
As mentioned earlier, HPV is classified either oncogenic or non oncogenic. Subgroup 16,18,31,45 being the highest risk, 33,35,39,51,52,56,58,59 being high risk, and 26,53,66,68,73,and 82 being classified as probable high risk. 
The others cause genital,plantar,or anogenital warts.
In 2009, Pharmaceutical Giant, GSK launched Cervarix, a bivalent vaccine, that provides immunity against subgroup 16 and 18. Upon the launch of Cervarix, the cost per dose for Gardasil drastically dropped. 
Both vaccines are administered over a period of 6 months in 3 doses, difference being on the second dose where Cervarix is given 1 month after the first dose while Gardasil being 2 months. 
My personal preference would be undoubtedly Cervarix.
Based upon the formulation on which the vaccine are made, you'll notice that GSK's Cervarix is far more superior than Gardasil. Cervarix's formulation includes the use of AsO4  as adjuvant that gives the immune system a boost in formation of antibodies and is maintained at a higher level for a longer period of time. 
To date,a study continues to be conducted and has been 7 1/2 years now. Modeling of Cervarix long term antibody kinetics predicts it's immunity remain detectable for at least 20 years, while immunity by Gardasil  begin to dwindle by the 5th year upon administration. 

Study on Cervarix is still ongoing today. 

Aluminium Hydroxide as the "key factor" for its rapid and sustainability of high antibody level against oncogenic HPV strains. 
The other important factor being that the latest studies conducted by GSK on more than 18,000 women indicated Cervarix does more than only provide immunity against HPV 16, and 18, but cross protection against HPV 31,33, and 45 as well! 

Hence, it provides immunity against the top 5 oncogenic subtypes of HPV. While Gardasil gives protection against subtype 16 and 18, subtype 6 and 11 aren't oncogenic but instead causes genital warts, which is a curable condition.

Therefore, ladies and gentlemen, in that sense, Cervarix would be a pentavalent  vaccine while Gardasil being a bivalent vaccine. 

Which vaccine then would you chose then?
Insist upon the box to be opened right in front of you, just to make sure you receive the right vaccine since you have paid for it. 

Original packaging comes in a pre-filled syringe of 0.5ml of vaccine. Enclosed are two needles of different sizes. 

It would be unbelievable but as I've worked in a  clinic (a well established clinic in Sri Petaling) which is a panel clinic to many restaurants that regularly sends their workers for typhoid vaccination, and since they've ran out of stock, and to save money, instead of injecting typhoid vaccine, the owner actually pre filled an empty typhoid vaccine ampoule with normal saline, and started injected patient with it. Unbelievable, but its true.
Hence, ladies, please make sure that your doctor opens the box right in front of you, and the plastic container that holds the syringe and needles is sealed. Make sure the doctor opens the seal in front of you!

The colour of the vaccine would be slightly cloudy, and not entirely transparent. 
Being ranked number 2 killer among women in Malaysia, with more prevalence among the Chinese, please go to the nearest clinic to inquire about the vaccine. 
Though the recommended age of vaccination is between the age of 10-45, but since occurrence of Cervical Cancer among the elderly of age between 65-70 form a significant percentage out of the overall number, I would still recommend vaccination even in individual above the age of 45.(Remember that HPV is non detectable from blood investigation, but only through HPV DNA Genotype test that identifies not only the presence of HPV, but it's subtypes as well, upon discovering abnormality in Pap smear. 

Love yourself, ladies. Don't think it won't happen to you. The fact that it is ranked 2nd as the cause of morbidity in Malaysia speaks for itself. 
Current market cost per dose is RM230-250. As part of our effort to promote this life saving 
revolutionary vaccine, Klinik Wan dan Keluarga, Bandar Sri Damansara charges only RM165 per dose or RM480 if paid together for the three doses. 

Call us at 62722678 (working hours Mon-Sat 9am - 7pm) for an appointment. It is part of our clinic policy to create an awareness among community on latest development in medicine that is available today.
Wondering why only RM165? No, we don't use fake or "other substitute". It's original Cervarix from GSK. 
Ever heard of cases where woman who regularly goes for annual Pap smear and was told to be normal, but died few months later of Cervical Cancer? Ever wonder why? Look out for out next post!