The health of our military service members and our Veterans is always a top line issue. Many suffer from illness and injury as a result of their service; and most are believed to be at higher risk for chronic sickness. Some of which is fortunately preventable.
Cancer is a top concern for much of the military community. To dig into the increased risk cancer poses to our Veterans, Fran Racioppi sat down with Team Maureen; an organization focused on bringing attention and prevention of HPV and HPV-related cancers to our Veterans.
Daniel Linskey, Kelly Welch and Dr. Emily Penick lead Team Maureen and founded the organization after the loss of their family and friend Maureen Russo.
Worldwide, a woman dies of cervical cancer every two minutes. It is the second-most frequent cancer in the world. The military community is twice as likely to develop HPV, yet immunization rates among our servicemembers are 50% of the civilian community. 90% of HPV-related cancers are preventable through immunization.
We broke down the facts of HPV, why it’s rising exponentially in our military, how it’s affecting both our women and men service-members, and what every single person, military and civilian, can do to prevent one of the deadliest, and preventable, cancers in society today.
Check out our conversation over-looking Plymouth Harbor and with Cardinals in the air. Follow us on social media, read the full episode on our website, then head over to our YouTube channel or your favorite podcast platform to catch this conversation and our follow-up with Danny as he shares how he led the Boston Police Department during the 2013 Boston Marathon bombing.
—
The cardinals showed up and the butterflies are out, I’m sure, because it’s a beautiful day on this kickoff to Memorial Day weekend. We’re right here on the South Shore of Boston. It’s awesome to be with you both and all three of you because we got Emily over here, who’s going to be remote. She’s joining us from Hawaii. Actually, she’s probably in a better position than we are.
Worldwide, every two minutes, a woman dies of cervical cancer. Every year, 500,000 women are diagnosed with cervical cancer, and there are over 250,000 deaths and 14,000 of those diagnoses are here in the US with over 4,300 American deaths. Those are huge numbers. It’s become the second leading cancer. It’s become the second most cancer for women worldwide. That’s alarming in so many ways. I want to start by just defining cervical cancer. What is it and why has it become so prevalent?
Yeah, thank you so much for having me. I’m very glad to be here. My name’s Emily Penick. I am a GYN Oncologist. I’m stationed at Tripler Army Medical Center in Honolulu, Hawaii. Since I am currently an active-duty member, I do need to caveat that the views that I express here in this show are mine and not those of the government, the Department of Defense, the Defense Health Agency, or the US Army.
All of that being said, cervical cancer is a cancer that develops at the mouth of the womb in a woman, at the cervix. While we are fortunate, through screening such as pap smears or HPV testing, to be able to detect abnormalities and have patients enter into either closer follow-up or have appropriate biopsies and procedures as needed, like you mentioned, this is still really a big issue for patients overall, but certainly within our active-duty population. It can have the potential to really affect military readiness and overall health.
I’m Kelly Welch. I’m the Executive Director of Team Maureen. We’re a nonprofit based in Massachusetts that’s dedicated to ending cervical cancer by educating about cervical cancer’s connection to HPV, which is a virus that we know causes almost all cervical cancers. We’re making sure that people know about the importance of prevention of HPV and early detection for cervical cancer is our mission.
I’m Dan Linskey. I’m a recovering cop.
Can you recover?
Yeah, I actually can sit sometimes at a restaurant with my back to the door and not think a ninja’s going to attack me. I have conversations with my kids now. I don’t do interrogations of them anymore, but I was a police officer for 28 years and the retired chief of the Boston Police Department. I was in charge of the marathon bombing attack and wound up trying to get folks off the street as quickly as possible. One to a hundred, two hours later, with Watertown cops, my cops, in a gun battle with the Tsarnaev brothers.
I am also very proud to be a member of the board of Team Maureen. Maureen was my cousin. We grew up very close together. Our kids were two weeks apart and are very close. This is an effort that my family has been involved with for years, trying to live on her reputation and her name and try and educate people so that they don’t have to miss Maureen at the Christmas table and the birthday events and the graduations that she’s missed.
Team Maureen started back in 2006 when we lost Maureen to cervical cancer, and that’s when our work began because nobody should die of cervical cancer. It’s completely preventable, and we know how to do that. That’s where our work has taken us over the years.
How do you get it?
Almost all cervical cancers are caused by HPV. It’s a virus. It’s very common. Almost everybody has it. Eight in ten people will have HPV in their lifetime, and for some people, it evolves into cancer. For most people, it goes away on its own. They never know they’ve had it, which means they’re spreading it all over the place without knowing it. Unfortunately, for people whose immune system can’t clear the virus, it can turn to pre-cancerous and cancers later in life. It is a sexually transmitted infection. It’s spread through any type of intimate sexual contact. It doesn’t require sex, so it spreads more easily than other common STIs that people talk about.
The numbers by HPV are large, too, with 13 million new cases every year. Most people, late teens, twenties and there’s actually contributions of HPV in six different types of cancer, cervical cancer being one of them. You talked about the fact that, for most people, the body clears the virus. They don’t think anything of it. I think that when we opened, we talked a little bit about why is this not talked about. I think, in my mind, that’s probably one of the reasons because it’s almost like, “If everybody has it, nobody has it.” Really, that’s not the case.
Very true. If people don’t recognize what the symptoms might be, they’re never going to know that they’re giving it to other people. They don’t know the risk.
Talk about the symptoms.
Many people are asymptomatic. For example, for our female patients, we often will detect this on a pap smear, and they may not have had any symptoms up until that point. The one symptom that people can often see would be something like genital warts, which is a clear, visible sign that there is something going on. For a lot of the strains of HPV that cause different types of cancers, until you have a more advanced stage of the disease, you may not have any symptoms until you start having abnormal bleeding, back pain or problems with urination.
Almost all cervical cancers are caused by HPV—a virus that 8 in 10 people will have in their lifetime.
How does it affect males versus females differently? Obviously, men don’t have a cervix, so they’re not going to have the onset of cervical cancer, but how are men affected versus women?
There are six different types of cancers that are caused by HPV. Cervix, vaginal, and vulvar, which would affect our female patients, penile cancers, which would affect males, anal cancers, which can affect both, and then head and neck cancers, which can affect both men and women. The cancer that we’re really starting to see men affected by, and one that’s actually on the rise, and really the most common HPV-associated cancer now, is the head and neck cancers, the ones at the back of the throat, the base of the tongue. Those in particular are affecting men in a 4 to 1 ratio when compared to women. It’s more commonly affecting men. We’re seeing a lot more cases, particularly in young White males. That’s definitely a big change that we’ve been seeing over the last several years.
How do you screen for it?
We start screening at age 21. You can start with either primary HPV screening or you can do cytology alone, which would be a pap smear. We have different types of guidelines based on age, as well as any prior abnormal pap smears that somebody would have. That’s the way we’re screening our female patients.
Unfortunately, we don’t have a screening test that’s universal to screen for anal cancers or head and neck cancers. A lot of times, other practitioners will do some of those screening exams. It’s like when you go to the dentist, they’ll look at your tongue, they’ll feel your lymph nodes, they’ll look at the back of the throat. If you’re going in for a colonoscopy, there’s an anal exam that’s part of that. If you’re coming in for a pelvic exam, we’re looking at the vulva, the vagina, the cervix, but we don’t have a universal screening test that’s available.
We did have some really exciting news because the FDA finally approved self-screening. That’s going to be a new way of being able to test for HPV for people who maybe don’t make it to the doctor or are uncomfortable going to the doctor. They’ll be able to eventually screen themselves and then send in those samples which will make a huge difference in accessibility, making sure that people can get tested no matter where they are.
There’s a lot of discussion about oral health and in a lot of the materials that Team Maureen has talked about and provided in a lot of the seminars and training you do, it talks about oral health and working with dentists. Can you go a little bit deeper on that and why that is so important as an early indicator?
Yeah. A number of years ago, even before the American Dental Association started talking to dentists about engaging in HPV prevention, we realized that if we really wanted to make a dent in the prevalence of HPV and the increase in vaccination, we needed more people engaged in the work. We started reaching out to dentists and hygienists and said, “You’re the ones that are going to see these cancers. You’re the ones that are doing the screening of feeling people’s throats and looking in the backs of their mouths for these head and neck cancers. Why not be at the forefront of HPV prevention?”
What we wanted to do was give them the tools, the language and the background information so that they could take that on as part of their regular standard of care in their dental office and not just screen someone’s feel their throat for a lump. At that same time, they’ll say, “I know your kid’s twelve. Have they been vaccinated yet? There’s a vaccine that prevents this cancer that I’m looking for.” We’ve done a lot of work over the last few years to provide the tools that dentists need to do that.
Let’s talk about vaccination. You brought it up. Ninety percent of HPV-related cancers are preventable through vaccination, yet vaccination rates are very low. Why?
90% of HPV-related cancers are preventable through vaccination yet vaccination rates are very low.
A lot of it has to do with the rollout of HPV vaccination. There’s been all these changes, which has complicated people’s understanding of who should be getting vaccinated and when. That has definitely not helped. Right now, we’re in vaccine fatigue after COVID, so that’s not helping either.
You’ve seen even a reduction from the numbers in post-COVID.
From the progress that we had made. I remember telling someone right before COVID, “I’m eventually going to put myself out of a job. This is going to be great. Everyone will be vaccinated and we’ll have ended cervical cancer,” and then COVID happened and all that went down the toilet. The other issue for the low vaccination rates is that HPV vaccine is not required for school entry in most states. It has a much lower vaccine uptake and lower rates than other common adolescent vaccines because it’s not required.
Imagine if there was research that said that we could vaccinate against lung cancer. My dad died of lung cancer. After having a lung removed, he lasted eight more years and died from complications from it. If that vaccine existed and we could stop that, that’s a no-brainer. I think it’s an education piece. We have to tell people what it is and what it isn’t. Take the boogeyman away from it and get people to understand that this is something that can help your kids not get cancer.
The numbers, again, speak for themselves. Active-duty military and veterans are twice as likely as civilians to develop cancers associated with HPV. There’s also a significant rise in HPV-related cancer in military males than in other demographics. Emily, let me turn this over to you. Why are we seeing those numbers so high in the military as compared to the civilian population?
Riskier behaviors are sometimes associated with younger age. With the various situations people are finding themselves in a military scenario, we know that we have a young active-duty population. We know that the most likely the demographic that’s going to acquire an HPV infection is usually someone between the ages of 15 and 24. That makes up a large component of our active-duty forces.
Risk factors such as multiple sexual partners and tobacco use are probably the two biggest ones. Those are things that can expose someone to HPV. Once you get that persistence, we start to get concerned about the pre-cancerous and cancerous lesions. That, coupled with low vaccination rates, as you touched on, there’s a study back in 2017, about 26% of active-duty women between the ages of 11 and 26 had initiated the HPV vaccine, but only 47% of those who initiated the vaccine actually completed it. When you add those risk factors plus the vaccination rates, that’s just adding to the recipe for the risk of developing cancer.
Talk a little bit deeper about the vaccine itself. What does the vaccination process look like and why would you start it and not complete it?
Really, when we talk about HPV vaccination, it really starts in that pediatric age range. Our family medicine providers, Team Maureen mission dental providers, pediatrics, you want to start vaccinating between the ages of 9 and 26. That is considered the appropriate time. Ideally, the younger we vaccinate, the more likely somebody is to complete the series.
If you’re under the age of fifteen, you only need a two-shot series. If you’re fifteen and older, it’s a three-shot series. I think that potentially, one drawback of the vaccine is that it does take multiple doses to consider everything as complete, as opposed to just receiving one dose and being done. We do have some newer data from the World Health Organization and other countries that potentially, one shot may be effective. Maybe we will see that in the future.
At this point in time, if you’re over the age of fifteen, you need three shots. If you’re under fifteen, it’s two. For those who are adults and are starting the series, you get your first dose and then 1 to 2 months later, the second dose, and four months after the second dose, you can get the third dose. That is potentially one reason where people might forget to complete the series or potentially a drawback to initiating and starting it.
Just 30% of female and 18% of male veterans have received the vaccine as compared to 62% of civilian women and 37% of civilian men. As Danny mentioned, when we’re sitting there in our SRP site and we’re getting anywhere from 2 to 14 shots in a single setting, why aren’t we just adding that to the list? Is that something DoD is looking at and why don’t they just add another shot and make it fifteen and get you on your way?
We were talking with some friends who do similar work in Maryland and had that same question posed to them, and they said it literally takes an act of Congress to add to the vaccine schedule that is required. There have been some shifts over time. The vaccine used to be available at bootcamp. That shifted a few years ago. Also, when that happened, we saw a drop in the rates then, making something that was bad already even worse. Maybe Emily can add to the details about what it would take to add it to the regular schedule.
I can’t speak on the official policy side of things, but exactly the quote that you said, it would really take our lawmakers looking at what our policies are as it pertains to our fighting forces in making that a mandatory vaccine. I think there are some things that we, as healthcare providers, can be doing certainly to improve those vaccination rates.
After COVID, I think anytime anyone hears the word mandate, it stirs up a lot of strong feelings. I truly don’t know if we would see a vaccine mandate in the future, and at least in the current climate that we’re in. However, it is my hope that one day that would be something, as an oncologist, that we would see. I would love it if I did not have to take care of any active-duty service members and their family members who have cervical cancer.
I think other things that could be considered would be an opt-out choice saying, like, “By default, we’ll give you this vaccine unless you say, ‘I don’t want it.’” Certainly, the work that we’re doing to improve education, both for patients, but certainly for healthcare providers, in recognizing how to give the vaccine, how to look at charts to see if people are due for it and making a strong recommendation. Studies have shown that if you receive a strong recommendation for getting the vaccine, someone is ten times more likely to receive the HPV vaccine. The words that we use and the recommendations that we give are very important in helping eradicate cervical cancers and all HPV-related cancers.
That’s why I think Team Maureen is trying to work with medical students. We are trying to get this conversation into them early on. When the vaccine for COVID was out, I got COVID and I got COVID bad. I sat down with my doctor and I said, “What do you think?” This is someone who I trust. He’s my primary care physician. He said, “If I were you, I would take it. Here’s the reasons why.”
I’ve built that relationship with him over the years. “All right, doc. If you think I should take it, I’m going to take it.” I took whatever series he recommended, but if we can get doctors and dentists to champion this and think about it and have conversations when these kids are younger, and when kids are in high school, “You have to get a physical to get into the military. You have to have a doctor sign off on it.” Having conversations with the primary saying, “If you’re thinking of going, let’s get your squared away so that if you get exposed to something, you are less likely to have the ability to catch it and the ability to spread it.”
That idea about making sure that providers have the tools to make those really strong recommendations is driving this project that we’re working on with Dr. Penick that will really try to educate military doctors and nurses, people who have the ability to influence whether or not a patient decides to get vaccinated. Making sure that they know all the background information, that they know the compelling reasons, and that they understand the connections to cancer. Hopefully, we’ll make a change that way in the absence of a mandated vaccine.
Tell me about Maureen.
A loving mother of two kids. She fell in love with her high school sweetheart, Mike, and they made it work. We went to Harvard and she was out at her school. She was a very talented athlete. She’d grown up dancing and gymnastics. One of the favorite movies back in the day that her brothers used to like to play was when she fell off, I don’t know if it was the parallel bars, which almost crushed her skull. The brothers thought that was funny because she got up and bounced up. She was a consummate competitor. She was competing in a gymnastics competition on a collegiate level, at a high level, with Olympic-quality athletes all around her. Maybe it was Scrabble or something else. She had to win.
I remember the kids. We used to vacation in Maine as young families together. My kids and her kids, she would make us go to the arcade, and every kid had to win something. We’d go to the water gun arcade balloon, and she would make sure that the parents were turning all of our water guns on one kid so they would win, and then someone else would win. It was fine when it was just us, but sometimes there were other people who wanted their kids to win prizes. It caused some concerns. She was passionate about everything she did. She worked hard with work, but she was passionate about her family and her friends.
She had a scare. She had an early diagnosis. We thought we got it. She’d just bought a brand-new house with Mike. The kids were doing great, and really, they were coming into a great time in their life. I think it was Thanksgiving. We were up the house and she talked about how her back was sore and how she was having back pain. I’m like, “What are you talking about?” She said, “Yeah, it’s just some back pain.” I’m like, “I don’t like that,” because my father’s cancer presented as pain in the back before he got it. I said, “You’re going to do something about that.” Unfortunately, she went and got checked, I think, a week or ten days after that and found out that she was sick again. She was surrounded by our family as she went through her treatments. She fought until the end and it brought us closer together.
It made us realize and look at today. We’re seeing the sun, we’re seeing the ocean, we’re seeing each other. I got to see my son and my wife this morning. Don’t take it for granted. I’m a retired cop. I’ve been to six funerals. My team and folks I went to wars with and have health issues and leaving. She left way too young. She had a whole life ahead of her. Her kids, her son is a standout lacrosse player in college, and her daughter is a genius who went to Oxford. After getting her undergrad and Master’s at Oxford, she decided to go to Cambridge. Now she’s speaking several different languages.
She crushed it in school and she’s crushed it as a young woman. The foundation that Maureen laid was amazing. That’s why it is personal. She was taken away from us at the height of her life. We don’t want some family to go through that if they don’t have to. Someone not to see their kids graduate from Oxford and Cambridge College and watch her son play lacrosse. He’s so big, they had to get him a special helmet because his head was too big to fit in the regular helmet and he crushes it.
She comes and says hello and she still wants to let us know that she’s in charge and ordering us around. She showed up right before we started filming as a cardinal here. That’s a family lore that she’s either a cardinal or a monarch butterfly. It seems like whenever we’re thinking of her or we’re going through something, either one of those shows up and you go, “It’s Maureen just checking in on us.” She was a special kid.
We should be able to get to that point where no one loses a loved one to cervical cancer. It’s completely within our reach. We can’t say that for other cancers. Australia, as a country, took on a broad vaccination campaign for all young people and a broad screening program to make sure that no one went unscreened. They’re anticipating they will not have cervical cancer by 2035. We know it’s possible. It’s not like we’re dreaming something that isn’t grounded in reality.
Education and awareness are the primary focus that you have at Team Maureen. Who are you educating? Who’s the audience and what are the different topics that you’re bringing to the table in those discussions?
Our education is basically in three different pillars. We focus on provider education, which we’ve already touched on, making sure that medical and dental providers have everything that they need to offer really strong recommendations for HPV vaccination. We know that provider recommendation is the biggest factor in whether or not people accept the vaccine. We do a lot of education with that.
We also want to make sure, with the ever-changing cervical cancer screening recommendations, that providers who do pap smears and HPV testing know exactly what they need to be doing and for who and on what schedule. A lot of provider education. The second pillar is focused on the public, recognizing that the more lay people know that HPV has ca onnection to cancer, when they go to the doctor, they’re more likely to say yes to the vaccine. They’re more likely to follow recommended screening requirements to catch cancer early.
We go to a lot of health fairs. We go to public events. We did a big campaign, going to baseball games, trying to reach those White men who we know have high head and neck cancer rates. We just talk to people. We just let them know, “Did you know that HPV causes cancer and it’s preventable?” Just to raise awareness.
Some of it’s parents, too. When you start having a conversation with your child’s primary care doctor and say, “This is a cancer. It’s a sexually transmitted infection,” a lot of parents want to shut that conversation down when they have 12, 13-year-old boys and girls. “We’re not getting there. We’re not going to have that conversation. I don’t want to have that thought in my head.”
We have to educate parents, “It is that, but yet there’s an ability. It doesn’t mean your kid is going to be sexually active to get this. It doesn’t mean that sexual activity is occurring. However, at some way down the line, it’s most likely that kid is probably going to get sexual at some point in their life. Maybe when they go into the military and they’re a young Marine or Army Ranger somewhere in the world. We probably should prepare them for it, just like we prepare them with measles, mumps and rubella and all the other stuff.”
I think sometimes parents want to push away from that conversation because of the connotation of where the disease comes from. I think we have to make sure doctors can have intelligent conversations and parents can hear it in more than one setting. The soccer team is talking about it, the baseball team’s talking about it, teachers are talking about it, and it takes that taboo away from it. It’s like, “What are you saying about my kid?” No, we’re not saying anything. We’re saying that this possibility in your lifetime, you are going to be exposed to it and you can do this and not have that exposure be fatal.
There’s a great example that providers often use. When do you put your bike helmet on? Do you put your bike helmet on before you get on your bike? Do you put it on when the car is coming at you or do you put it on when you’ve already been hit by the car? You don’t wait. It’s prevention. You put it on long before you have any opportunity to have a bike accident.
There’s no such thing as too early when it comes to prevention. The vaccine is like a bike helmet—you put it on before the crash happens.
To comment on the concern about sexual activity among adolescents, there’s a wonderful poster that the CDC made at one point in time, and it says, “You’re not opening the door to sex. You’re closing the door to cancer.” Studies have looked at vaccination rates and sexual activity and have shown that there’s no increase in sexual activity among adolescents and teens who receive the HPV vaccine. Getting that message out that this is really about cancer prevention is such a key part of the vaccination strategy.
How do we get people to take action?
The more than we normalize conversations about, “Did your kid get this yet,” instead of, “Are you going to get this?” The more that we just make it the common social norm that everybody gets vaccinated and we talk to our friends and family about that, the quicker we’ll get to the threshold where everybody is protected. Not only are we trying to reach providers at Army medical centers and making sure they have the right messaging, but we’re also doing some work with the military spouse advocacy network, making sure that spouses who are the ones who have to take kids to doctor’s appointments when someone is deployed, that they’ve got the information that they need to.
I’m sure Emily will attest to this. I come from a world of a bunch of folks who think they’re invincible and are often the last ones to think that they actually have something wrong. The last ones who ever want to go see a doctor or ever go talk about any of their issues. I think that there’s a tremendous opportunity to bring what you’re doing into the Special Forces community and into our Green Berets and Navy SEALs, who I know you do a lot of work with them, and get in front of these communities and get people to understand that this is one of those conversations that you got to have. You think you’re a badass, but cancer doesn’t care if you’re a badass.
We have colleagues who tip the spear and they came home and cancer got them. Nothing could get them, but cancer got them. If you’re going out on a mission, you won’t leave your rifle behind. You wouldn’t leave your vest off. You can put it on because that’s what gets you through and protect you. If I have a vaccine that can prevent you from getting cancer, that’s a no-brainer. That’s a tool in the toolbox that you want every veteran to have. Let the governments pick it up. If we didn’t get it as a kid, let’s get it now. Nip it in the bud.
We don’t have a solution to the suicide problem with our veterans yet. We’re kicking it around, trying to figure it out. This is an actual solution that we could deploy that would have results. We could put more resources on our suicide challenges and try to figure out what that is to try and get those, “I’m made of steel. I don’t need any help. Nothing’s wrong with me,” when in fact there is. Especially the world you you’ve been in, where you’ve been, what you’ve seen, what our veterans have endured, we need to be putting everything we can to support them when they’re back home.
I can actually just chime in with one little tidbit here. We’ve been talking a lot about prevention, but I just want to put out there that even if somebody has been affected by HPV and you weren’t previously vaccinated, you can still get the vaccine. It’s actually recommended for up to age 45, and again, 9 to 26 is all comers. We want to be vaccinating you, but ages 27 to 45 can also get the vaccine.
It’s a shared decision-making conversation that happens between the provider and the patient. We know that if we vaccinate women who have previously had cervical dysplasia, which is a precancerous lesion, if they get the vaccine, they have a decreased likelihood, up to 65% decreased reduction in that cervical dysplasia coming back, even if they’ve already been infected with HPV. Regardless of what your HPV status is, it’s not too late for someone to get the vaccine. There can still be health benefits for that. Our catch-up campaigns are certainly an important part of that as well.
Whatever we can do to continue to spread the word, we’re going to do it.
Thank you.
I 100% agree with you. We live in this world where there are so many things we can’t control. When there are those things in the world that we can control, we need to take the initiative and we need to do everything we can. We need to make sure that there’s enough education, awareness and initiative. One of the concepts that we put forward in leadership all the time is we have to have a bias to action. We’ve got to be willing to make decisions, do things, and take initiative. This is one of those initiatives we have to take.
Thank you for kicking off the weekend here with me. It’s a beautiful day. I know Maureen was here with us as we had this conversation. I look forward to spreading this message and supporting Team Maureen in everything you’re doing. Let’s get involved with the Green Beret Foundation. Let’s set that up and really have some impact across the community for this.
Thank you very much. We appreciate it.
