What can we learn from gynecologists about addiction? National Center for Addiction Training ABAM-Foundation Conrad N. Hilton Foundation.

What can we learn from gynecologists

about addiction? National Center for Addiction Training

ABAM-Foundation

Conrad N. Hilton Foundation

The Spectrum of Cervical Cancer

Early History of Cervical Cancer .

-The path from the #1 cancer to the #10

BCE - Descriptions by the Egyptians, Greeks and Romans

2nd Century - Soranus (98-138) designed a “dioptra”

1600s - Nikolaas Tulpius (1593-1674)

surgical removal of the cervix

1600s - Herman Boerhaave (1688-1738)topical chemical treatment of cervical cancer

1700s – Matthew Baillie – (1761-1818)published clear pathological images of cervical cancer

Early Controversies (early1800s)

What is cancer?Systemic disease that localizesLocal disease that becomes systemic

How does cancer spread?Adjacent tissue become abnormalAbnormal tissue spreads and replaces adjacent

tissue

How should cancer be diagnosed? By clinical examinationBy microscopy

More Recent History (late1800s)1840s – James Marion Sims (1813-1883)

designed the “duckbill” speculum

1840s – Herman Lebert (1813-1878)described the microscopic appearance of cancer

1898 – Ernst Wertheim (1864-1920)performed first radical hysterectomy for cervical cancer

1895 – Wilhelm Roentgen (1845-1923)discovered X-rays

1898 – Marie Curie (1867-1934) discovered radioactivity (noted effects on tumors,

1902)

Later Controversies (c. 1900)

How should cancer be described?Clinical descriptionBy the TNM staging system

Which treatment strategy is best?Measured: Less for limited disease, more for

advancedQualitative: Early curative – palliation for late disease

What kind of treatment should be used?Radiotherapy: External X-ray versus local radiumSurgery: Vaginal versus abdominal hysterectomy

Early 20TH Century

1925 – Hans Hinselmann (1884-1959) – colposcope

1927 – Jane E. Lane-Clayton published cohort studies

1928 – George N. Papanicolaou (1883-1962) – Pap smear

1928 – Walter Schiller (1887-1960) – iodine staining

1938 – Use of acetic acid to aid visualization

1943 – Traut & Papanicolaou publication about natural history

1946 – Aylesbury spacula

1949 – HPV described by electron microscopy

State-of-the-art: 1930 -1950

No treatment worked well for late stage cervical cancer

Microscopic diagnosis was the norm

Clinical staging by the TNM system

Screening strategies were knownColposcopy (Germany and South America)Pap smears (Northern Europe and North America)

Personal risk factors were known

Prevention and early diagnosis was considered the key

Barriers to prevention 1950–1960

Known risk factors associated with shame

Association of colposcopy to Nazi Germany

The politics of cervical cancer prevention

Public not aware of the importance of screening

The discomfort of the pelvic examination

Physicians were slow to adapt (Einsellung effect)

Limited workforce of cytopathologists

Recent Milestones

1951: Kara-Enelf -> Colposcopic flash photography

1953: Catherine MacFarlan -> Follow biopsies, Tx PRN

1960: Textbooks of colposcopy (in French)

1964: British NHS offered Pap smear screening

1976: HPV found in cancer specimens

1988: Bethesda system to classify Pap smears

1990: HPV linked to cancer (not HSV)

2006: HPV immunization

Current Questions

Why have cervical cancer rates fallen?Number 1 cancer c. 1900 (nearly ½ of all cancer

deaths)Number 10 cancer in 2000 (2.5% of cancer deaths)

Why do some women still develop cancer despite screening?

What are the best screening intervals?

Is it possible to improve the sensitivity of the Pap smear?

Will the HPV immunization prevent cancer?

Parallels with cervical cancer

Differences for sure

Some things are common

Our understanding of addiction is now about where cervical cancer was in the mid-20th centuryThere are some things we don’t knowThere are some things we know

Lessons can be learned

Progress forward may be similar (via science)

What don’t we know?

Etiology: Nature v. Nurture

Process: Neurobiological v. Behavioral

Pathophysiology: Changes in brain structure v. Function

Natural history: Progressive v. Spontaneous remissions

Diagnosis: Clinical (DSM-5) v. Biomarkers

Staging: Does not apply v. Applicable

Treatment: Behavioral v. Medical

Screening: Are screening and early treatment effective?

What do we know?

Genetics: Born with a genetic load

Gene expression: Influenced by environment

Epidemiology: Peak problems late teens and 20s

Course: Spontaneous remissions do occur

Treatments: Seem to be effective (studies are poor)

Primary prevention: Abstinence is effective

Secondary prevention: Seems to be effective

The Spectrum of Cervical CancerNor

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Spectrum of Alcohol and Drug Abuse

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Education Assess risks Screening Intervene Treatment

Take Home Lessons

In the 1920s Jane E. Lane-Clayton reviewed the literature, conducted cohort studies, and evaluated the state-of-art treatments for advanced cervical cancer. She concluded that better treatments were not the answer to reduce the burden of this disease; however, she also concluded that it could only be lessened by prevention, screening and early aggressive treatment.

Likewise, it appears unlikely that we will be able to treat our way out of the current addiction epidemic and that it will always be better to prevent addiction rather than waiting for patients to “hit bottom.”

Conclusions

We can’t treat our way out of this problem

Need to expand our focus upstream Primary prevention Secondary prevention

Need to add Risk Assessment to SBIRT (RASBIRT)

Addiction is a pediatric disease!