Treatment of Cervical Cancer

Where is the cervix located?

Cervix is a part of the female reproductive system which is the lowermost part of the womb (or uterus). This opens into the vagina.

What is cervical cancer?

When cells of the cervix either fail to reach the stage of death or reproduce uncontrollably, it forms a tumour. This tumour spreads and obstructs normal function causing problems which may be life-threatening if not recognised early.

Who is at risk?

Cervical cancer is one of the commonly occurring cancers in women. It affects almost 13,000 women in the U.S every year. But, on the bright side, early detection has an excellent prognosis. Cervical cancer is more common in the following cases:

1. HUMAN PAPILLOMA VIRUS: this virus has many subtypes. Not all of them cause cervical cancer. Some simply cause genital warts and lesions. But types 16 and 18 causes around 75% of the cervical cancers. HPV is spread through sexual contact with affected persons. This is why it is important to have trusted and safe sexual relations. Having multiple sexual partners, becoming sexually active at a young age, low immune system and contracting other sexually transmitted diseases put you at an increased risk for HPV.
2. SMOKING: active and passive smoking of tobacco puts women at an increased risk of developing cervical cancer. It also increases the rate of spread of the cancer. Studies show that women who are heavy smokers are at three times more risk of developing cervical cancer.
3. ORAL CONTRACEPTIVES: Women who have a habit of consuming contraceptives for a long period of time (say 5-7 years) are at an increased risk of developing cervical cancer.
4. MULTIPLE PREGNANCIES: studies show that women who have had three or more full term pregnancies are at an increased risk of developing cervical cancer.
5. EARLY PREGNANCY: although women tend to reach puberty much before the age of 18, having a full-term pregnancy before the age of 17 puts them at an increased risk compared to those who conceive at 25.
6. SOCIO-ECONOMIC STATUS: women with better socio-economic status have better hygiene facilities, fewer pregnancies compared to women from poorer backgrounds. This increases the risk of developing cancer.

When to see a doctor?

Although signs and symptoms can vary widely from person to person, some important signs can help an early detection:

• Abnormal vaginal bleeding
• Painful menstrual bleeding
• Vaginal bleeding after sexual intercourse
• Bleeding or spotting between menses (periods)
• Bleeding after menopause
• Longer, heavier menstrual cycles
• Pain during sexual intercourse
• Pain in the lower belly or pelvis
• Watery or bloody vaginal discharge which might have a foul odour
• Advanced stage symptoms include weight loss, fatigue, back pain, leg pain, swollen legs, fractures, and rarely urine or faeces discharge from vagina.

TYPES OF CERVICAL CANCER:

There are two main divisions:

1. Squamous cell carcinomas: these begin at the flat, thin cells at the bottom of the cervix. This accounts for almost 80 to 90 percent of cervical cancers.
2. Adenocarcinomas: these develop in the glandular cells that line up in the upper portion of the cervix. They account for 10 to 20% of cervical cancers.

Other rare types include:

• Adenosquamous carcinoma
• Small cell carcinoma
• Neuroendocrine tumour
• Glassy cell carcinoma
• Villoglandular adenocarcinoma

STAGING:

Staging is an important step to diagnose and plan the best treatment for the patient. A generalised form of the staging is as follows:

• STAGE 0: precancerous cells are present
• STAGE 1: cancerous cells have grown and spread to deeper layers of cervix and probably to the uterus and nearby lymph nodes
• STAGE 2: the cancer is now spread beyond uterus and cervix but not to the walls of the pelvis or lower part of the vagina. It may or may not have affected he lymph nodes.
• STAGE 3: the cancer cells are present in the lower part of vagina or walls of the pelvis. It may be blocking the uterus and the urinary tubes. It may or may not have affected the associated lymph nodes.
• STAGE 4: the cancer has spread to the bladder or rectum and is growing out of the uterus. It may or may not affect the lymph nodes. In advanced stages, it spreads to distant organs like liver and lungs.

How do we detect it?

1. PAP smear test: a simple, cost effective test that requires minimum equipment, minimum discomfort, and quick. A swab is wiped onto the mucosal layer of the cervix, collecting the secretions and cells and are deposited onto a slide which is then examined under a microscope for cancerous or precancerous cells. This test has a 50% false negative and should not be the confirmatory test.
2. Colposcopy: a lighted microscope is used to visualise the external surface of the cervix. If any abnormal-looking tissues are found, a small scraping of cells are taken for biopsy. This is sent to the laboratory for testing. It does not require anaesthesia and the discomfort level is similar to that in PAP smear.
3. Conization: a cone shaped portion near the cervical canal is removed. This is done with the help of an electrically-heated thin loop of wire known as LEEP(Loop Electrical Excision Procedure). The cone-shaped segment can also be removed using cold knife conization technique. This tissue is then sent for biopsy. The procedure is performed under local anaesthesia in the doctor’s office.
4. X-Rays, CT, MRI: these tests are performed once the presence of cancer is confirmed, to know the extent of cancer spread in the pelvis.

What are the treatments available in India?

With the advent of recent technology, the prognosis of cervical cancer has improved sevenfold. The early detection of cervical cancer through regular cervical screening plays an extremely important role in its successful treatment. It is advised that women over the age of 30 undergo regular pelvic examination once in 3 years. This is not required in those who have undergone hysterectomy already.

The treatment modalities available in India are:

1. SURGERY:
2. Hysterectomy: it refers to a procedure which includes removal of the uterus with a small portion of the vagina. Simple hysterectomy is the removal of the uterus and cervix with the cancerous tumour. It is done in early stages of cervical cancer. Radical hysterectomy is the removal of the cervix, uterus, a part of the vagina, and associated lymph nodes along with the cancer. Both these procedures render the woman infertile.
3. Trachelectomy: this procedure involves removal of the upper vagina and cervix. It is done in initial stages and preserves the fertility of the womb.
4. Pelvic exenteration: It involves removal of cervix, uterus, surrounding lymph nodes, and parts of other organs depending on its location.
5. RADIATION THERAPY: radiations are another treatment option. Both external radiation therapy and brachytherapy (insertion of radioactive sources near the tumour for fixed duration of time). If patient wants to conceive, preservation of eggs must be considered as an option.
6.  CHEMOTHERAPY: low doses of chemical medications that have the capacity to kill cancer cells are injected into the vein. This treatment is given as an adjunct to radiation therapy. It is usually reserved for advanced stages of cervical cancer.
7. PALLIATIVE CARE: Special medical care that focuses on offering pain relief and relief from other symptoms of the illness. Special palliative care doctors are appointed for the patient and the family.

PREVENTION:

Although there is nothing definitive that can be done to prevent cancer altogether, some precautionary measures can be taken to reduce the risk of cervical cancer:

• Vaccination against HPV
• Protected sexual practices using condoms and other barriers.
• Avoid smoking and chronic alcoholism
• Routine PAP smear test