January is cervical health awareness month.

Dr. Ritu Salani, a gynecologic oncologist and professor in the department of obstetrics and gynecology at UCLA, sat down with Daily Bruin science and health contributor Nick Mouchawar to discuss cervical cancer awareness, prevention strategies and the importance of routine screening.

Salani received her medical degree from Northeast Ohio Medical University and completed her residency in obstetrics and gynecology at Emory University School of Medicine, followed by her fellowship in gynecologic oncology at Johns Hopkins University School of Medicine. She now serves as the director of gynecologic oncology at UCLA. Her work focuses on surgical and systemic cancer care, as well as clinical trials and research aimed at improving patient outcomes and clinical practices.

This interview has been edited for length and clarity.

Daily Bruin: Can you explain what cervical cancer is and how it typically develops?

Ritu Salani: Cervical cancer, as the name implies, is cancer arising from the cervix. This is actually a cancer that’s associated with an HPV (human papillomavirus) infection. About 80% of people are exposed to HPV at some point in life. If the virus persists, it can actually lead to cellular changes and then cervical cancer.

DB: How do HPV infections lead to cervical cancer, and why is HPV such a central focus in cervical cancer prevention?

RS: HPV is considered the causative agent for almost all cervical cancers. There are some exceptions, but it accounts for a majority – almost 100% – of cervical cancers. The reason why the cervix is so susceptible to it is because … it’s directly exposed, direct contact via sexual activity.

The cervix can actually incorporate that – or cervical cells to incorporate – the HPV virus into their DNA or their genome, and that can lead to malignant transformation.

DB: How effective is the HPV vaccine in preventing cervical cancer, and what age groups benefit most from vaccination?

RS: The HPV vaccine has been actually approved for 20 years now. … It’s actually very effective. There are different types of HPV vaccinations, and there’s one that targets nine different HPV strains, seven of them being associated with cancer, two of them being associated with lower-risk HPV-related diseases like genital warts or condylomas.

The efficacy rate really does depend on the age that you get the vaccine. Preteen, I would say, is the most effective. Ages 11 and 12 – but really before age 17 – there has been remarkable data that’s shown that reduction of cancers is about 90% compared to an unvaccinated person.

DB: Beyond the vaccine, what preventative steps can people take to reduce their risk?

RS: A screen test is designed to detect changes in a normal cervix setting without symptoms. It’s like getting your car maintained – you’re not waiting for a problem. The key behind cervical cancer screening is we want to assess patients who are at that higher risk for HPV or cellular changes of the cervix.

Most recommendations start in the 20s. Some may say start at age 21, which is pap testing, and then some may say start at age 25 with pap and HPV testing. And both of these are very reasonable strategies – they just depend on which guidelines your doctor, provider is following. Then the recommendation is to perform pap and HPV testing, which we call co-testing, and that is usually repeated every five years if it’s negative. It’s a new strategy. We used to do it every year, but with the HPV testing, we are actually very able to be much more targeted about patients who may be at higher risk. So, if you’re HPV negative, going five years without another HPV or cervical pap test has actually been shown to be very safe and effective – and we do this with other tests like colonoscopies, which may be every 10 years. We have to remind ourselves to keep those dates on target. If you’re HPV positive or if you have cellular changes, then you may need sooner intervention or evaluation. Those patients shouldn’t have that longer duration because they may be at higher risk for precancerous changes, or ultimately cancer.

DB: There are new screening innovations, like at-home HPV self-collection test kits. How do you see these changing public participation in screening?

RS: We know that the consistency between self-collection and position collection is actually pretty comparable. It is important that it must be ordered by a provider, and there’s a key reason for this. It’s not like you can just go to the store and pick up an HPV test and do it. … It’s really important that patients know that if there is an abnormal result that will probably require provider evaluation for further analysis. Some patients have a lot of anxiety around pelvic examinations, and so for those patients, this may be an ideal measure.

DB: What improvements in treatment or survivorship have you seen in the most recent years?

RS: The biggest advancement has been with the incorporation of immunotherapy. This has made an impact in both progression for how long patients live without the disease and overall survival from cervical cancer. It makes sense because we know HPV is an infection, so boosting up the immune system is a logical approach to treat it, and it has been shown to be effective. However, we still struggle with patients who have advanced or recurrent disease. Cure rates are actually still very low, and average survival is about two years.

DB: What are some common myths or misunderstandings about cervical cancer and the HPV vaccine that you encounter in your practice?

RS: I’m going to start with the HPV vaccine. First one, vaccinations have kind of gotten a bad rap recently. Everybody associates a lot of stigma with HPV and that’s a misconception because most people will have seen HPV in their lifetime. It’s been around for 20 years and is one of the most safe vaccines. The biggest side effect of a vaccine is pain at the injection site.

This really is a decision that parents should be informed of. We need to make sure they understand the benefit of it – and I’m talking about cervical cancer, but there are other HPV-associated cancers – and data is starting to emerge that the HPV vaccine may have benefit across the board. This includes cancers of the head and neck, anal cancers and other cancers of the lower genital tract for females.

For cervical cancer, don’t wait until you have symptoms. I’ve heard a lot of patients who say, “Oh, well, it’s very treatable or curable,” and that is true in early stages, but most patients who aren’t receiving routine screening care actually present in more advanced stages. As I shared with you earlier, survival rates are actually very low for patients in advanced and recurrent stages. The importance of screening and early detection cannot ever be overstated.

DB: How do social, economic or cultural barriers affect access to cervical cancer screening and treatment, and what can be done to address these inequities?

RS: Cervical cancer is more common in patients with uninsured or underinsured access to health care, and that usually is typically the lower socioeconomic groups. We also see disparities across different races. So we know that Black patients have higher rates of mortality from cervical cancer, stage for stage, and they have lower rates of follow up for abnormal pap testing. Asians and Native Americans have lower screening rates. I hope that self collection for HPV testing increases, helps reduce some of these barriers. It doesn’t eliminate the need for a health care provider, but hopefully it’ll help reduce some of those barriers.

In my opinion, and this is maybe a little bit high in the sky, but having some better processes for HPV vaccine access (could address disparities in care). There’s talks about administering it in schools like we do with other vaccinations or having it available at retail settings where you can get your flu vaccine. Wouldn’t it be nice if you could also get your vaccine and eliminate the healthcare facility as part of that? There’s some opportunities, but there’s a lot of hurdles and logistics to overcome with that. For cervical cancer screening barriers otherwise, it’s an exam that may promote anxiety and reassuring patients. Now, with normal exams, it can be every five years – so that may be something that hopefully helps reduce anxiety, if normal, of course.

I do hope the self swabs help overcome that (disparities in access to care). That’s the only thing in the near future, but understanding (of) the disease is improving as well. … The other thing is just destigmatizing HPV. With HPV being sexually transmitted, patients may be embarrassed or not talk about it. But I think the best thing we can do is educate our friends, family members, et cetera.

DB: If you could give one clear piece of advice to the student community about cervical cancer awareness, what would it be?

RS: Vaccination and screening. I think we have an opportunity to eradicate cervical cancer, and those are the keys to do it.