Indian Woman and Cancer: Cervical Cancer

Most cases of cervical cancer are found in women younger than 50. It rarely develops in women younger than 20. Many older women do not realize that the risk of developing cervical cancer is still present as they age. About 20% of cervical cancers are found in women older than 65. These cancers, however, rarely occur in women who have been getting regular tests for cervical cancer before they were 65. Even in 21 st century, cervical cancer remains in one among the top affecting Indian women.

Genesis of Cervical Cancer:

Most cervical cancers begin in the cells in the transformation zone ie endo and ecto cervix. These cells do not suddenly change into cancer. Instead, the normal cells of the cervix first gradually develop pre-cancerous changes that turn into cancer. Doctors use several terms to describe these pre-cancerous changes, including cervical intraepithelial neoplasia (CIN), squamous intraepithelial lesion (SIL), and dysplasia. These changes can be detected by the Pap test and treated to prevent cancer from developing.

Types of Cervical Cancer

Cervical cancers and cervical pre-cancers are classified by how they look under a microscope. The main types of cervical cancers are squamous cell carcinoma and adenocarcinoma.

Most (up to 9 out of 10) cervical cancers are squamous cell carcinomas. These cancers develop from cells in the ectocervix and the cancer cells have features of squamous cells under the microscope. Squamous cell carcinomas most often begin in the transformation zone (where the ectocervix joins the endocervix).

Most of the other cervical cancers are adenocarcinomas. Adenocarcinomas are cancers that develop from gland cells. Cervical adenocarcinoma develops from the mucus-producing gland cells of the endocervix. Cervical adenocarcinomas seem to have become more common in the past 20 to 30 years.

Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.

Although almost all cervical cancers are either squamous cell carcinomas or adenocarcinomas, other types of cancer also can develop in the cervix. These other types, such as melanoma, sarcoma, and lymphoma, occur more commonly in other parts of the body.

Risk factors:

Human Papilloma Virus (HPV) Infection

Infection by the human papilloma virus (HPV) is the most important risk factor for cervical cancer. HPV is a group of more than 150 related viruses. Some of them cause a type of growth called papillomas, which are more commonly known as warts.

  • HPV can infect cells on the surface of the skin, and those lining the genitals, anus, mouth and throat, but not the blood or internal organs such as the heart or lungs.
  • HPV can spread from one person to another during skin-to-skin contact. One way HPV spreads is through sex, including vaginal, anal, and even oral sex.
  • Different types of HPV cause warts on different parts of the body. Some cause common warts on the hands and feet; others tend to cause warts on the lips or tongue.

Certain types of HPV may cause warts on or around the female and male genital organs and in the anal area. These are called low-risk types of HPV because they are seldom linked to cancer. Other types of HPV are called high-risk types because they are strongly linked to cancers, including cancer of the cervix, vulva, and vagina in women, penile cancer in men, and cancers of the anus, mouth, and throat in both men and women. It is believed that a woman must be infected with HPV in order to develop cervical cancer. Although this can mean infection with any of the high-risk types, about two-thirds of all. Cervical cancers are caused by HPV 16 and 18. Infection with HPV is common, and in most people, the body can clear the infection by itself. Sometimes, however, the infection does not go away and becomes chronic. Chronic infection, especially when it is caused by certain high-risk HPV types, can eventually cause certain cancers, such as cervical cancer. Although there is currently no cure for HPV infection, there are ways to treat warts and abnormal cell growth that HPV causes.

Human Papilloma Virus (HPV) Infection | SSD Hospital

Smoking

When someone smokes, they and those around them are exposed to many cancer-causing chemicals that affect organs other than the lungs. These harmful substances are absorbed through the lungs and carried in the bloodstream throughout the body. Women who smoke are about twice as likely as non-smokers to get cervical cancer. Tobacco by-products have been found in the cervical mucus of women who smoke. Researchers believe that these substances damage the DNA of cervix cells and may contribute to the development of cervical cancer. Smoking also makes the immune system less effective in fighting HPV infections.

Immunosuppression

Human immunodeficiency virus (HIV), the virus that causes AIDS, damages a woman’s immune system and puts them at higher risk for HPV infections. This might explain why women with AIDS have a higher risk for cervical cancer. The immune system is important in destroying cancer cells and slowing their growth and spread. In women with HIV, a cervical pre-cancer might develop into invasive cancer faster than it normally would. Another group of women at risk for cervical cancer are those taking drugs to suppress their immune response, such as those being treated for an autoimmune disease (in which the immune system sees the body’s own tissues as foreign and attacks them, as it would a germ) or those who have had an organ transplant.

Chlamydia Infection

Chlamydia is a relatively common kind of bacteria that can infect the reproductive system. It is spread by sexual contact. Chlamydia infection can cause pelvic inflammation, leading to infertility. Some studies have seen a higher risk of cervical cancer in women whose blood tests and cervical mucus showed evidence of past or current chlamydia infection. Women who are infected with chlamydia often have no symptoms. In fact, they may not know that they are infected at all unless they are tested for chlamydia during a pelvic exam.

A diet low in fruits and vegetables

Women whose diets don’t include enough fruits and vegetables may be at increased risk for cervical cancer.

Being overweight

Overweight women are more likely to develop adenocarcinoma of the cervix.

Long-term use of oral contraceptives (birth control pills)

There is evidence that taking oral contraceptives (OCs) for a long time increases the risk of cancer of the cervix. Research suggests that the risk of cervical cancer goes up the longer a woman takes OCs, but the risk goes back down again after the OCs are stopped, and returns to normal about 10 years after stopping.

Intrauterine device use

Some research suggests that women who had ever used an intrauterine device (IUD) had a lower risk of cervical cancer. The effect on risk was seen even in women who had an IUD for less than a year, and the protective effect remained after the IUDs were removed. Using an IUD might also lower the risk of endometrial (uterine) cancer. However, IUDs do have some risks. A woman interested in using an IUD should first discuss the possible risks and benefits with her doctor. Also, a woman with multiple sexual partners should use condoms to lower her risk of sexually transmitted illnesses no matter what another form of contraception she uses.

Having multiple full-term pregnancies

Women who have had 3 or more full-term pregnancies have an increased risk of developing cervical cancer. No one really knows why this is true. One theory is that these women had to have had unprotected intercourse to get pregnant, so they may have had more exposure to HPV. Also, studies have pointed to hormonal changes during pregnancy as possibly making women more susceptible to HPV infection or cancer growth. Another thought is that pregnant women might have weaker immune systems, allowing for HPV infection and cancer growth.

Being younger than 17 at your first full-term pregnancy

Women who were younger than 17 years when they had their first full-term pregnancy are almost 2 times more likely to get cervical cancer later in life than women who waited to get pregnant until they were 25 years or older.

Economic status

Many low-income women do not have easy access to adequate health care services, including Pap tests. This means they may not get screened or treated for cervical pre-cancers.

Diethylstilbestrol (DES)

DES is a hormonal drug that was given to some women between 1940 and 1971 to prevent miscarriage. Women whose mothers took DES (when pregnant with them) develop clear-cell adenocarcinoma of the vagina or cervix more often than would normally be expected. These types of cancer are extremely rare in women who haven’t been exposed to DES. There is about 1 case of vaginal or cervical clear-cell adenocarcinoma in every 1,000 women whose mothers took DES during pregnancy. This means that about 99.9% of “DES daughters” do not develop these cancers.

DES-related clear cell adenocarcinoma is more common in the vagina than the cervix. The risk appears to be greatest in women whose mothers took the drug during their first 16 weeks of pregnancy. The average age of women diagnosed with DES-related clear-cell adenocarcinoma is 19 years. Since the use of DES during pregnancy was stopped by the FDA in 1971, even the youngest DES daughters are older than 40 − past the age of highest risk. Still, there is no age cut-off when these women are felt to be safe from DES-related cancer. DES daughters may also be at increased risk of developing squamous cell cancers and pre-cancers of the cervix linked to HPV.

Having a family history of cervical cancer

Cervical cancer may run in some families. If your mother or sister had cervical cancer, your chances of developing the disease are 2 to 3 times higher than if no one in the family had it. Some researchers suspect that some instances of this familial tendency are caused by an inherited condition that makes some women less able to fight off HPV infection than others. In other instances, women in the same family as a patient already diagnosed could be more likely to have one or more of the other non-genetic risk factors previously described in this section.

Cervical Cancer History | SSD Hospital

Signs and symptoms of cervical cancer

Women with early cervical cancers and pre-cancers usually have no symptoms. Symptoms often do not begin until cancer becomes invasive and grows into nearby tissue. When this happens, the most common symptoms are:

  • Abnormal vaginal bleeding, such as bleeding after vaginal sex, bleeding after menopause, bleeding and spotting between periods, and having (menstrual) periods that are longer or heavier than usual. Bleeding after douching or after a pelvic exam may also occur.
  • An unusual discharge from the vagina. The discharge may contain some blood and may occur between your periods or after menopause.

Pain During Sex

These signs and symptoms can also be caused by conditions other than cervical cancer. For example, an infection can cause pain or bleeding. Still, if you have any of these symptoms, see a health care professional right away. Ignoring symptoms may allow cancer to grow to a more advanced stage and lower your chance for effective treatment. Even better, don’t wait for symptoms to appear. Have regular Pap tests and pelvic exams.

Pain During Sex in Cervical Cancer | SSD Hospital

Diagnosis:

Medical history and physical exam

First, the doctor will ask you about your personal and family medical history. This includes information related to risk factors and symptoms of cervical cancer. A complete physical exam will help evaluate your general state of health. The doctor will do a pelvic exam and may do a Pap test if one has not already been done. In addition, your lymph nodes will be felt for evidence of metastasis (cancer spread).

The Pap test or liquid-based cytology is a screening test, not a diagnostic test. It cannot tell for certain if you have cervical cancer. An abnormal Pap test result may mean more testing, sometimes including tests to see if cancer or a pre-cancer is actually present. The tests that are used include colposcopy (with biopsy), endocervical scraping, and cone biopsies.

Colposcopy

If one has certain symptoms that are suggestive of cancer or if Pap test result shows abnormal cells, you will need to have a test called colposcopy. The patient will lie on the exam table as you do with a pelvic exam. A speculum will be placed in the vagina to help the doctor see the cervix. The doctor will use a colposcope to examine the cervix. The colposcope is an instrument that stays outside the body and has magnifying lenses. It lets the doctor see the surface of the cervix closely and clearly. Colposcopy itself is usually no more uncomfortable than any other speculum exam. It can be done safely even if you are pregnant. Like the Pap test, it is better not to do it during your menstrual period.

The doctor will put a weak solution of acetic acid (similar to vinegar) on your cervix to make any abnormal areas easier to see. If an abnormal area is seen, a biopsy (removal of a small piece of tissue) will be done. The tissue is sent to a lab to be looked at under a microscope. A biopsy is the best way to tell for certain if an abnormal area is a pre-cancer, true cancer, or neither. Although the colposcopy procedure is usually not painful, the cervical biopsy can cause discomfort, cramping, bleeding, or even pain in some women.

Cervical biopsies

Several types of biopsies can be used to diagnose cervical pre-cancers and cancers. After these procedures, patients could feel mild cramping or pain and might also have some light bleeding.

Colposcopic biopsy

For this type of biopsy, the cervix is examined with a colposcope to find the abnormal areas. The cervix might be numbed with a local anesthetic before the biopsy. Using biopsy forceps, a small section of the abnormal area is removed.

Colposcopic biopsy - SSD Hospital

Endocervical curettage (endocervical scraping)

Sometimes the transformation zone (the area at risk for HPV infection and pre-cancer) cannot be seen with the colposcope so something else must be done to check that area for cancer. This means inserting a narrow instrument (called a curette) into the endocervical canal (the part of the cervix closest to the uterus). The curette is used to scrape the inside of the canal to remove some of the tissue, which is then sent to the lab for examination.

Cone biopsy

In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The tissue removed in the cone includes the transformation zone where cervical pre-cancers and cancers are most likely to start.

A cone biopsy is not only used to diagnose pre-cancers and cancers. It can also be used as a treatment since it can sometimes completely remove pre-cancers and some very early cancers.

The methods commonly used for cone biopsies are the loop electrosurgical excision procedure (LEEP), also called the large loop excision of the transformation zone (LLETZ), and the cold knife cone biopsy. With both procedures, you might have mild cramping and some bleeding for a few weeks.

  • Loop electrosurgical procedure (LEEP, LLETZ): In this method, the tissue is removed with a thin wire loop that is heated by electricity and acts as a small knife. For this procedure, a local anesthetic is used, and it can be done in your doctor’s office.
  • Cold knife cone biopsy: This method is done in a hospital. A surgical scalpel or a laser is used to remove the tissue instead of a heated wire. the patient will receive anesthesia during the operation (either a general anesthesia, where you are asleep or a spinal or epidural anesthesia, where an injection into the area around the spinal cord makes you numb below the waist).

Cone Biopsy, Cervical Cancer - SSD Hospital

Having any type of cone biopsy will not prevent most women from getting pregnant, but if a large amount of tissue has been removed, women may have a higher risk of giving birth prematurely.

EUA ie Examination Under Anaesthesia is an integral part of accurate staging. Though it is not made mandatory investigation prior to subjecting one for definitive treatment it aids in proper localizing the lesion, biopsing it appropriately especially if needs colposcopy biopsy or conization or LEEP.

Examination Under Anaesthesia, Cervical Cancer | SSD Hospital

Tests for women diagnosed with cervical cancer

If biopsy results show that you have cervical cancer, your doctor may order certain tests to see how far cancer has spread. Many of the tests described below are not needed for every patient. Decisions about using these tests are based on the results of the physical exam and biopsy.

Cystoscopy and proctoscopy

These are most often done in women who have large tumours. They are often not needed if the cancer is caught early.

In cystoscopy, a slender tube with a light is placed into the bladder through the urethra. This lets the doctor check your bladder and urethra to see if cancer is growing into these areas. Suspicious areas that look like cancer can be biopsied during the procedure for testing.

Cystoscopy can be done under a local anesthetic, but some women may need general anesthesia (where you are in a deep sleep). Your doctor will let you know what to expect before and after the procedure.

Proctoscopy is a procedure that lets the doctor see the inside of the rectum through a lighted tube to check for spread of cervical cancer into that area.

Your doctor may also do a pelvic exam while you are under anesthesia to find out if cancer has spread beyond the cervix.

Imaging tests

If your doctor finds that you have cervical cancer, certain imaging tests may be done to look inside the body. These tests can show if and where cancer has spread, which will help you and your doctor decide on a treatment plan.

Chest X-ray

Your chest may be x-rayed to see if cancer has spread to your lungs. This is very unlikely unless the cancer is far advanced.

Computed Tomography (CT)

CT scans are usually done if the tumour is larger or if there is concern about cancer spread. For more information, see CT Scan for Cancer.

Magnetic Resonance Imaging (MRI)

MRI looks at soft tissue parts of the body sometimes better than other imaging tests. Your doctor will decide which imaging test is best for your situation.

Intravenous Urography

Intravenous urography (also known as intravenous pyelogram, or IVP) is an x-ray of the urinary system taken after a special dye is injected into a vein. This test can find abnormal areas in the urinary tract, caused by the spread of cervical cancer. The most common finding is a blockage of the ureters (tubes that connect the kidneys to the bladder) by cancer. IVP is rarely used for patients with cervical cancer because CT and MRI are also good at finding abnormal areas in the urinary tract, as well as others not seen with an IVP.

Positron Emission Tomography (PET Scan)

PET scans use glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. This test can help see if cancer has spread to lymph nodes. PET scans can also be useful if your doctor thinks cancer has spread but doesn’t know where, because they scan your whole body.

PET scans are often combined with CT scans using a machine that can do both at the same time. The combined PET/CT test is rarely used for patients with early cervical cancer, but may be used to look for more advanced cancer or if radiation treatment is a possibility. For more information on this test, see Nuclear Scans for Cancer.

FIGO Staging of Cervical Cancer:
Ultimate staging is surgical and treatment is stage directed.

FIGO Staging of Cervical Cancer

Treatment Armamentarium:

Treatment Armamentarium | SSD Hospital

In nut shell stage l & lla→ surgery, stage llb onwards nonmetastatic ca cervix→ chemoradiation as definitive treatments.

Tricky management issues:

Management issues:
Fertility preservation and ca cervix:
Treatment of carcinoma cervix with live pregnancy.
Laparoscopic and robotic radical hysterectomy

Recurrent cervical cancers:

[Post surgery] Rx of rec ca cervix→ Rx = radiation / chemoradiation.
[Post radiation] Rx of rec ca Cervix→ Rx = surgery.

Exenteration procedure for recurrent ca cervix: its resorted to recurrences of cervical cancers following chemoradiation, especially central recurrences, involving bladder or rectum or both. It is also indicated in patients with per premium presentation with fistula to bladder or rectum.

Prognostic Factors:

Prognostic Factors, Cervical Cancer | SSD Hospital

Survival Data:

  • These are the most recent statistics available for survival by the current staging system.
  • The 5-year survival rate for people with stage 0 [in situ] cervical cancer is about 93%.
  • For stage IA cervical cancer, the 5-year survival rate is about 93% For stage IB cancer, the 5-year survival rate is about 80%.
  • For stage IIA cervical cancer, the 5-year survival rate is about 63%. For stage IIB cancer, the 5-year survival rate is about 58%.
  • The 5-year survival rate for stage IIIA cervical cancer is about 35%. For stage IIIB cancer, the 5-year survival rate is about 32%.
  • Stage IVA cervical cancer has a 5-year survival rate of about 16%, and stage IVB cancer has a 5-year survival rate of about 15%. Still, there are often treatment options available for women with these stages of cancer.

Remember, these survival rates are only estimates – they can’t predict what will happen to any individual person. We understand that these statistics can be confusing and may lead you to have more questions. Talk to your doctor to better understand your specific situation.

 

Dr. Hitendra Patil

 

 

 

 

 

 

 

Dr. Hitendra Patil

Consultant Cancer Surgeon, SSD Hospital

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