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INSIDE HEALTH

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Programme 9.

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TX:Ìý 18.03.14Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Coming up today:Ìý Scar free operations, the Holy Grail of surgery, but just how close are we to removing an appendix through a patient’s mouth or their vagina?

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Cancers of the mouth, tongue and throat – there has been a dramatic rise in the number of cases in the UK over the last 30 years, I’ll will be asking why.

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And does eating later in the evening really make you more likely to pile on the pounds? We examine the science behind the latest diet fad that claims you can consume whatever you like as long as you don’t eat in the evening.

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But first cancer of the cervix.Ìý Could testing for infection with the human papilloma virus take over from smears as the main screening tool for the disease? A committee advising the Food and Drug Administration in American has just unanimously approved the adoption of the new technology and it is likely that the UK will follow suit.

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The test works on the principle that HPV – which at least half of all sexually active women will pick up at some stage - accounts for nearly all cases of cancer of the cervix. And that testing for it is a more accurate way of picking up those women most at risk from the disease.

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Professor Jack Cuzick is Director of the Wolfson Institute of Preventive Medicine in London.

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Cuzick

The conventional way of looking for abnormalities that might lead to cervix cancers, the so-called Papanicolaou smear or the cytology test, this basically takes a small scrap of cells from the cervix and looks at them under a microscope and looks for abnormalities in the cells.Ìý And that’s been the conventional approach of detecting things that are pre-cancerous, many, many years before they become cancer and it’s been very successful.

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I guess almost two decades now it was discovered that in fact virtually all cervix cancer is caused by a virus – the human papilloma virus.Ìý And there are about 14 types of that virus that can actually cause cervix cancer.Ìý And as a consequence of that it turns out that it’s better to screen for the virus and in fact you screen for the virus in exactly the same materia you would do for the conventional cytology smear but you look for the virus not the changes that the virus causes.Ìý And that turns out to be a more sensitive approach – it picks up things where the changes aren’t so clear yet.Ìý The test is much more sort of high tech in a way.Ìý Cytology is basically staining a conventional glass slide and a specialist actually looking at that slide for abnormalities.Ìý There’s a subjective nature to it, different people see slightly different things, it’s quite tedious, time consuming, people get tired and they make mistakes.Ìý The HPV test, in contrast, is a laboratory test, it’s done essentially by a machine, it’s completely reproducible, you get the same answer every time, and it’s black and white.

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Porter

The Americans look set to adopt HPV testing as the first step in screening for cancer of the cervix.Ìý So what’s the situation here in the UK?

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Cuzick

Well it’s interesting.Ìý The earliest trials to actually look at HPV as a screening test were all done in the UK, so we should be at the lead but in fact we’ve been really quite slow in implementing this.Ìý HPV testing is now used as a secondary test for women that have cytology abnormalities that are slightly abnormal but not that serious to decide how to manage them.Ìý And the real push forward to use it as a primary screening test has been rather slow – there are five sentinel sites which are actually evaluating it but in fact it hasn’t been introduced nationally yet.Ìý I think we’re very close now, we’d hope in the next year or two we might get an announcement to go forward.

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Porter

If HPV testing is adopted here too what will be the difference between having a negative HPV test and a normal smear?

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Cuzick

A negative HPV test provides much more reassurance than a negative PAP test.Ìý Routinely we do cytology now every three years up to age 50 and then every five years.Ìý HPV tests don’t need to be done any more often than every five years.Ìý So we can extend the interval and probably after two negative HPV tests it can be extended even beyond five years.Ìý That’s not fully established yet.Ìý But you get so much more protection because you’re detecting an earlier change that if it’s truly negative there’s many, many years before something serious can develop.

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Porter

But, given how widespread HPV infection is, can’t a woman who tests negative go on to catch the virus the very next day. What happens then?

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Cuzick

Certainly women will routinely be coming in contact with HPV and will be getting exposed all the time but in fact the time from exposure to cancer is probably of the order of 10-15 years and the time from exposure to even early changes is a few years.Ìý So many studies have shown now that if you’re negative for HPV you get very few abnormal changes for at least five years and possibly longer.

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Porter

So what happens to women who test positive?

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Cuzick

The investigation of HPV positive women is really an area where there’s still ongoing work.Ìý At this stage the first thing you’d do would be to do a cytology test and interestingly if you do cytology knowing the woman is HPV positive you look more carefully at that smear and you actually detect more things than if you’re doing it routinely.Ìý If that is positive then I think there’s good evidence for going on to hospital referral and getting what’s called a colposcopy to have a look at the cervix and see if there’s anything abnormal there.Ìý If that’s negative that’s an area where there’s a lot of interest now in how best to manage these women.Ìý We know that many, many human papilloma virus or HPV infections are transient.Ìý Most HPV infections will actually be cleared spontaneously by the body with no change.Ìý The number that actually go on to become persistent and once they become persistent they are going to cause disease at some stage is small, it’s probably in the order of 5 to may be 10%.

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Porter

Routine vaccination against HPV was introduced into the UK six years ago, so will vaccinated women need to be tested?

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Cuzick

The current vaccine against HPV really only focuses on the two major types – type 16 and type 18 – that causes about 70-75% of the cancers and about 50% of the abnormalities.Ìý So they won’t need to be screened as often but the risk will still be there because there’s still this 30% or so that haven’t been picked up – haven’t been stopped by the vaccination.Ìý So screening will need to take place but probably less often, maybe once every 10 years.Ìý Now there is also a new vaccine that’s just been announced and we’ve just seen the initial results which have been presented in a meeting but not yet published which has nine types in, seven of them against cervix cancer and the other two are against genital warts.Ìý The expectation is is that that will prevent more than 90% of cervix cancer.Ìý So one of the long term questions will be if you’ve had this new vaccine you may not ever need to be screened again but certainly with the current vaccines screening will be important.

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Porter

Professor Jack Cuzick.Ìý And listening to that in our Glasgow studio is Dr Margaret McCartney. Margaret, we should start by clarifying that women are not going to notice much difference between this new test and a conventional smear.

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McCartney

Absolutely and I think it’s important to know that the NHS is already using HPV testing, so if a woman has a smear test which show some abnormalities on it she’s automatically tested for HPV as part of the screening process in order to know what best to do for that lady next to all.

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Porter

And actually having the HPV test is fundamentally like having a smear isn’t it?

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McCartney

Yes, so the cells that are taken from the neck of the womb, from the cervix, are tested for HPV virus.

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Porter

It seems good news if you test negative?

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McCartney

Yeah although we know that HPV is an incredibly common virus, we know that about 80% of the population will have been exposed to it at some point in their life and we know that age is the biggest risk factor for it.Ìý So when you look at women who are aged say under 20 50-60% of them will have had it, 50% aged between 20 and 21, so an awful lot of people will be harbouring the HPV.Ìý And when you go and look for it you’re going to find an awful lot of virus but actually most people will have got rid of it by themselves.Ìý So about 70% of people clear the virus by themselves in one year, 90% in two years, so you’ll be picking up an awful lot of people who have got the HPV virus in their cervix that is actually going to get better by itself anyway.

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Porter

And this is one of the criticisms of the existing smear programme, that it unnecessarily worries an awful lot of women.

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McCartney

Yeah, I mean I think in order not to be worried we have to have really good information for women, women should know that actually the chances are at some point you’re going to test positive for this but also the chances are that your body’s going to get rid of it for you.Ìý We’re only really concerned about the women who are harbouring the virus, who don’t get rid of it over a long period of time and who are at much higher risk of developing cervical abnormalities because of that.

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Porter

But I suppose the bottom line is would the introduction of this test improve the accuracy of our cervical cancer screening programme?

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McCartney

Yeah, so what the offer then would be and what the FDA in America have said that instead of doing a cellular examination first, a smear test first, you would test for HPV first.Ìý And that’s probably a more accurate test in terms of who’s more likely to go on to develop problems.Ìý But the problem is that the sieve is quite wide, you’re going to catch an awful lot of women in that sieve who actually were never going to develop problems because of it.Ìý So it’s a better test but it’s at the cost of an awful lot more women being told that they’ve got something potentially wrong.Ìý The other thing I think it’s really important for women to know is that screening is only for people who don’t have any cervical symptoms or symptoms from the vagina.Ìý So if you have symptoms like bleeding after sex or an offensive discharge or anything else – pain during sex – something like that, something that might possibly be a symptom of cervical cancer screening test isn’t a useful test, you need different diagnostic tests and they’re available no matter what age you are, whether you’re eligible for screening or not.

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Porter

Margaret McCartney thank you very much.

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Cancer of the cervix isn’t the only malignancy associated with human papilloma virus, it’s now known to play a key role in cancers affecting other parts of the body too.

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The number of cases of oral cancer in the UK has nearly doubled since the ‘70s and increasing rates of HPV infection are thought to be partly responsible.

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Oral cancer is an umbrella term for cancers of the lips, mouth, tongue, tonsils, and back of the throat or pharynx. Established risk factors include exposure to alcohol and tobacco, but they don’t explain the recent rise in the number of cases – now up to more than six and a half thousand a year here in the UK. A rise that has been accompanied by a significant increase in the number of those cancers infected with HPV.

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Andrew Shackie is a head and neck cancer surgeon and clinical lecturer at the University of Liverpool.

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Shackie

In the mouth and pharynx in 20 years we’ve seen a rate of HPV positive malignancy rise from around 10-15% in the late ‘80s, early ‘90s, up to 70% as we see it today.Ìý

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Porter

That’s a significant increase Andrew, how worried are people in your profession?

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Shackie

It is a significant increase and it’s such that many authors are describing it as an epidemic.Ìý I’m not sure whether we’d go quite as strong as that but certainly we’re seeing a rapid change in the incidence within our own practice and that will translate through to increasing numbers of individuals and so a burden for the health community and a burden for the health system to actually have to treat.

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Porter

Which strains of HPV virus are we talking about – are they the same ones that are causing the problems in cancer of the cervix?

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Shackie

They are the same strains that are causing cervical cancer, however, the relative proportions that we see in head and neck cancer are quite different in that HPV 16 causes probably in excess of 95% of HPV positive head and neck cancers and if we contrast that to the cervix it’s only little over 50-60% driven by HPV 16.Ìý

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Porter

Now HPV 16 and 18 are not new strains of HPV, they’ve been around for a long time, why are we seeing an increase in oral cancers as a result of them?

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Shackie

I think we have to be honest and say that we don’t know.Ìý There have been a variety of theories put forward and one would be a change in sexual practice, perhaps 20, 30, 40 years ago that has allowed an increase exposure to virus to the oral cavity and to the oropharynx and a consequent increase in potential for malignancy to develop.

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Porter

How do you catch this virus?

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Shackie

It’s more than likely to be sexual contact in the same way as cervical cancer is caught through intimate sexual contact.Ìý We know that number of sexual partners and number of oral sexual partners strongly associated with an increased risk of HPV positive head and neck malignancy.Ìý So we think, and we’re certainly by no means sure, that oral sex may well be playing a role in HPV positive head and neck malignancy.

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Porter

Do we have any idea of the timescale from exposure to HPV as to when you might be likely to run into trouble if you’re unlucky?

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Shackie

So this is typically males in their mid-50s and we would assume that their exposure to high risk HPV occurs around the time of sexual debut.Ìý

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Porter

So this is potentially a long slow process from infection to the development of the cancer.Ìý Of course with cancer of the cervix we can use that to screen for abnormalities.Ìý Is there any similar thing that we can do in the mouth and throat?

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Shackie

There’s not.Ìý Unfortunately unlike cervical cancer we can’t screen, we’re talking about an anatomical area that is difficult to assess – we’re talking about the tonsils – and even within the tonsils the HPV positive tumours we suspect develop within crypts or deep areas well and truly within the oropharynx.Ìý So no it’s not accessible, it doesn’t have the benefits of cervical cancer.Ìý And even if we were to look at surrogates, whether it would be carriage of HPV within saliva, they don’t appear, at this stage, to be of sufficient standard to actually screen individuals.

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Porter

Of course we now have a vaccine against HPV 16 and 18 that’s given routinely to girls here in the UK to prevent against cancer of the cervix.Ìý Is there any evidence that it would offer similar protection against head and neck cancers that are caused by HPV?

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Shackie

We do know that from a large Costa Rican vaccine trial that the incidence of HPV DNA being detected in the oral cavity of vaccinated women fell significantly within the arm of the trial that were vaccinated, or the 95% efficacy.Ìý So we know that it will drop HPV incidence, what we don’t know is whether it will actually translate on to dropping the rates in malignancy.Ìý But it would be sensible to suggest that if we vaccinate individuals with a systemic vaccine that it would have a flow on effect across all sites that are affected by HPV positive malignancy.

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Porter

Andrew Shackie.Ìý And you will some useful links to more information about the causes, symptoms and treatment of oral cancers on the Inside Health page of the Radio 4 website.

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Now we like to bust myths here on Inside Health so the team couldn’t ignore Raymond Blanc when he said he believes French women are slimmer than their British peers because they don’t eat so late. And he is not alone in thinking that a late meal is more likely to end up on your hips or indeed your waistline. The latest fads to hit the dieting world are eight hour diets promising that you can eat anything you like between nine and five, and that you will lose weight as long as you don’t eat anything after this.

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But is there any science behind the approach? Susan Jebb is Professor of Diet and Population Health at the University of Oxford.

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Jebb

If we do controlled studies in the laboratory where we balance the number of calories in the different ways of eating it really makes absolutely no difference whatsoever.Ìý The body’s perfectly good at assimilating the calories as they come in and then expending them later when it needs them.

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Porter

Because tradition would have it or traditional belief would have it that if you eat too late, as is advocated by this diet, that the food hangs around and somehow goes straight to your hips or your tummy or your chin.

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Jebb

Well of course what happens in our controlled metabolic studies is not the same as what happens at home.Ìý So if at home you eat well during the day and carry on eating into the evening of course you’re going to consume more energy than you would if you stopped eating at six o’clock or seven o’clock in the evening.Ìý So I think the question is what eating pattern best helps you to control the number of calories because at the end of the day it’s that total number of calories that really matters for your body weight.

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Porter

But this concept that if you eat something after five, six, seven o’clock, depending on who you believe, that it’s going to go straight to your hips and your tummy is nonsense effectively?

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Jebb

Well you won’t burn it off immediately because you’re going to be less physically active than you were during the day but you’ll burn it off the next day.Ìý Your fat stores are like your deposit account in the bank and so if you don’t need it right now you’ll store the money but you can draw on it later.Ìý Lots of these studies have done very short measurements, so they give you a meal and then they just measure it for the next couple of hours.Ìý So if you have a meal you’ll instantly oxidise the carbohydrate and you store the fat, so they say oh look all that fat’s been stored.Ìý But if you do longer term studies over 24 hours what you realise is it all evens out in the end.Ìý And so I think we are often misled by very short term studies.Ìý If you absolutely control everything people are consuming and you measure over a whole day…

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Porter

There’s no difference depending on…

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Jebb

… there really isn’t, there’s one study that found a difference and it’s done in sort of eight people or something and all of the others don’t and that’s just chance.

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Porter

Calorie for calorie then, if two people are eating – they’re identical people who are eating exactly the same amount of calories per day does timing of food have any difference on your likelihood of weight gain?

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Jebb

No.Ìý Not on their weight.Ìý But if you eat small and often there may be some metabolic advantages, you might perhaps lower your risk of cardiovascular disease or diabetes because you get a more stable metabolic profile, if you like, across the day.

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Porter

So rather than have the three meals a day, this is what we might call grazing effectively?

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Jebb

Absolutely.Ìý And that may be a very good strategy for reducing metabolic risk if you can keep a lid on your total calorie intake.Ìý So in the laboratory it works really well but in real life when people are eating small and often it’s very easy to lose track of just how much you’ve consumed.

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Porter

So how are these diets working – the diets that say you can eat what you like between nine and five?Ìý I mean presumably if the book’s a big success, people are buying it because it’s working?

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Jebb

They’re working by setting rules and at least for a period of time some people will find those rules helpful.Ìý So most people consume most of their calories in the later part of the day and so if you set a rule that says I won’t eat after six or seven o’clock in the evening for most people that will cut out a batch of calories which they will not make up for, at least not wholly, at other times of the day.Ìý And so it's one of a number of rules people might adopt to help them control their calorie intake.Ìý And if that works for you that’s fantastic, there’s absolutely no problem with that but let’s not pretend it’s something magical about the time of day that you eat.

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Porter

It’s quite clever though isn’t it that if you are going to market a new diet this is something – I remember being taught a long time ago breakfast like a king, lunch like a prince and dine like pauper – it is old folk lore.

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Jebb

Oh it feeds into sort of cultural stereotypes and tradition and so on and that’s often very appealing.Ìý We absolutely know that obesity has increased in recent decades and so I think it’s natural to look back to how our grandparents ate and to revert to that way of doing things when most people had their main meal often at lunchtime.Ìý But the truth is they did a whole mass of things differently – they had a much smaller variety of foods, they had less convenience and process foods and of course they did rather more exercise than most of us do today.Ìý We may not be quite so keen to adopt the whole of the 1940s diet.

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Porter

Professor Susan Jebb who seems pretty clear that you are WHAT you eat, rather than WHEN you eat.

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And if there is an issue that is confusing you, please do get in touch.Ìý You can e-mail insidehealth@bbc.co.uk.

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Jane e-mailed after last week’s item questioning whether it was right to refer to sugar as being addictive:

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Jane

Regarding the issue of sugar one of your male contributors said there was no such thing as a sugar craving.Ìý Perhaps he should consider the female PMT cycle and the associated sugar cravings brought on by hormonal changes.

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Porter

To be fair to the experts that we interviewed Jane I think they were suggesting that cravings are not necessarily indicative of an addiction.Ìý I don’t think they were disputing the fact that we all occasionally crave some sugars.Ìý

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Rosie wasn’t very pleased with our item on thrush:

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Rosie

I was disappointed by the piece on thrush.Ìý I’ve suffered with symptoms for over 30 years.Ìý My first outbreak occurred when I was 19, tests always show candida present.Ìý I no longer have baths, or soap, have tried every home remedy going as well as using products designed to reduce thrush growth.Ìý Saying candida isn’t thrush was really annoying.

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Porter

Rosie, we didn’t actually say that candida wasn’t thrush.Ìý What we said was that some cases of so-called recurrent thrush are nothing of the sort because they’re misdiagnosed.Ìý Obviously in cases where the diagnosis is confirmed that requires a different approach to management but that was beyond the scope of the item, which is why I directed listeners to our website where there was information on diagnosing and managing recurrent cases like yours.Ìý So I hope that that helps.

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Mark Wescott – a Consultant Eye Surgeon from Moorfields – got in touch to comment on our recent item on advances in cataract surgery where we looked at multi-focal lenses that correct both near and distance vision negating the need for specs. We pointed out that they are generally only available privately and Mr Wescott didn’t want listeners to think NHS patients were getting second rate treatment.Ìý Standard fixed lenses – the type offered to most NHS patients - can give excellent results, he writes, and multifocal lenses are not suitable for everyone.

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And talking of advances in surgery, how about having your gallbladder removed by a technique that leaves no scar? It’s the holy grail of surgery and closer than you think thanks to NOTES – Natural Orifice Transluminal Endoscopic Surgery.

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Mikael Sodergren is Clinical Lecturer in Surgery at Imperial College London.

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Sodergren

It’s doing surgery through natural orifices, so your mouth, vagina, anus, entering that cavity, going through the lumen into the abdomen where you like to do the operation, then pulling back and closing the hole in that orifice and leaving in effect no scars in the abdomen.Ìý Now the background to this is that over the years we’ve tried to minimise the number of incisions or cuts that we make in the abdomen or the tummy wall and by doing so we’ve actually found that patients benefit – patients benefit in that they have less pain, they have less complications and they return faster to normal activities.

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Porter

So we’re now in a position where keyhole surgery for a lot of operations inside the stomach is the standard approach now, so what’s the advantage of orifice surgery?

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Sodergren

The perceived advantage – and it is a theoretical advantage because we’re still in the early phase of development of natural orifice surgery – but the theoretical advantage is that by eliminating all the incisions in the tummy wall and the abdomen then we eliminate all of the complications that are associated with these.Ìý And that can be anything from hernias to adhesional scarring on the inside and obviously by doing that we also presume that we eliminate a lot of the pain that’s associated with these.Ìý All that results in faster healing, a faster return to normal activities and perhaps also even less complications.

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Porter

It’s okay to talk about this being scar free surgery but let’s assume you’re going in through the vagina or in through the mouth and out through the stomach, there’s an incision somewhere it’s just hidden isn’t it?

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Sodergren

That’s exactly right but what we have found is that the premise is that the complication of this incision and if you will the effects of this incision will be more favourable than the incisions on the abdominal wall.

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Porter

You see I find that slightly counterintuitive because if you’re suggesting that you go in through the vagina, which is not a sterile environment, and nor is going in through the mouth and cutting through the bowel wall, it sounds to me like there’s a potential for things to go wrong.

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Sodergren

There is absolutely and this is sort of where it leads to where we are today because laparoscopic or keyhole surgery has been around for 20 years and a few years ago we had this idea of not having any incisions at all in the abdominal wall and going through natural orifices.Ìý Now the problem with that is that we actually don’t have the technological backup, we don’t have the technological kit to be able to do that as effectively as we want.Ìý But when it comes to the complications of the incision itself we can’t really tell yet what the complications are but we do know that we have to have kit that will enable us to close these holes, if it’s in the stomach to close the hole in the stomach, very, very effectively because a complication from a leak from that, for instance, would be intolerable for many procedures which are deemed very, very safe.Ìý The advantage that we have with transvaginal surgery is that the gynaecologists of course have been doing forms of transvaginal surgery for a very long time – they’ve been doing operations on the uterus and on the ovaries.Ìý So the advantage that gives us is that we know that it’s extremely, extremely safe with very little complications.

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Porter

Well talk me through what’s actually involved in doing an operation like that and the sort of things that you might use the transvaginal approach for.

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Sodergren

So at Imperial College we’ve done the first transvaginal operations in the United Kingdom, we did our first operation in 2010 and that was transvaginal removal of the gallbladder.Ìý Now I have to say that worldwide it’s acknowledged that we don’t do pure natural orifice surgery yet, we use a form of transabdominal assistance and that’s normally a very small five millimetre port through the belly button that no one can see or hardly even feel and that proves us with the security that when we do the transvaginal incision we can see it on the other side that it’s safe.

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Porter

Tell me about your equipment that you’re using.

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Sodergren

So we have – at Imperial College we have developed a robot called the iSnake and that’s been running for over four or five years now and it’s essentially to try to develop a robot which will enable us to perform flexible access surgery more efficiently than with currently available instrumentation.Ìý So it’s a clever robot and also the fact that it’s robotic will allow us to harness the real advantages of machine learning and computer science within surgery.

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Porter

Well the obvious thing is that of course men don’t have vaginas, so you’re only going to be able to use that orifice in half of your patients, so you’d be looking at going through the mouth and through the stomach for a lot of people?

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Sodergren

Through the mouth and then through the stomach, we’ve found that if you look at perception among different populations we find that that’s a relatively acceptable thing to do because we do endoscopies and so on but the problem is we have to have a secure way of closing the hole that we make and we have to have a robot that is clever enough to have the capabilities to do what we want it to do.

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Porter

If all goes to plan what sort of procedures do you see being done by people’s mouths in 10 or 20 years’ time?

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Sodergren

If we have the available technology we could do absolutely any procedure that you can imagine.

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Porter

A very confident Mikael Sodergren, who assures me that clever robots – like their prototype iSnake – could one day do emergency surgery outside hospitals, without anaesthetic. Such as removing an appendix by sending the iSnake in through the patient’s mouth. And not a mark left on them. All very science fiction.

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Back to science fact for next week’s programme, when, among other things, I will be learning more about a new approach to tackling insomnia and it doesn’t involve any pills. Join me then to find out more.

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ENDS