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

2. The Spectrum of Cervical Cancer

3. -The path from the #1 cancer to the #10 Early History of Cervical Cancer. -The path from the #1 cancer to the #10 BCE - Descriptions by the Egyptians, Greeks and Romans 2 nd 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

4. Early Controversies (early1800s) What is cancer? Systemic disease that localizes Local disease that becomes systemic How does cancer spread? Adjacent tissue become abnormal Abnormal tissue spreads and replaces adjacent tissue How should cancer be diagnosed? By clinical examination By microscopy

5. 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)

6. Later Controversies (c. 1900) How should cancer be described? Clinical description By the TNM staging system Which treatment strategy is best? Measured: Less for limited disease, more for advanced Qualitative: Early curative – palliation for late disease What kind of treatment should be used? Radiotherapy: External X-ray versus local radium Surgery: Vaginal versus abdominal hysterectomy

7. Early 20 TH 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

8. 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 known Colposcopy (Germany and South America) Pap smears (Northern Europe and North America) Personal risk factors were known Prevention and early diagnosis was considered the key

9. 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

10. 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

11. 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?

12. 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-20 th century There are some things we don’t know There are some things we know Lessons can be learned Progress forward may be similar (via science)

13. 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?

14. 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

15. The Spectrum of Cervical Cancer Normal Dysplasia CIS Local Met. Vaccine Colposcopy Cone Hyst Pelvic Surgery

16. Spectrum of Alcohol and Drug Abuse Abstinence Non-problem use At-risk use Abuse Dep Education Assess risks Screening Intervene Treatment

17. Take Home Lessons could only be lessened by prevention, screening and early aggressive treatment. 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.”

18. 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!