Cervical cancer is cancer of the cervix. The cervix is the lower part of the uterus or womb, and is connected to the upper vagina. It is the structure that dilates during childbirth to allow the baby to traverse the birth canal. This is the area where cervical cells are most likely to become cancerous. It is called the transformation zone.
Cervical cancer develops when abnormal cells in the lining of the cervix begin to multiply out of control and form pre-cancerous lesions. If not successfully treated at an early stage, cervical cancer is capable of invading through the wall of the uterus into adjacent areas and sometimes can spread through the bloodstream or the lymphatic system to parts of the body away from the uterus.
Cervical Cancer Symptoms
- Abnormal bleeding: Women with cervical cancer may experience abnormal vaginal bleeding. This can be heavy or light bleeding during the month.
- Unusual heavy discharge: An increased vaginal discharge is also a symptom of cervical cancer. It may be foul smelling, watery, thick, or contain mucus. It varies from woman to woman. It is important to report any unusual vaginal discharge to your doctor.
- Pelvic pain: Pelvic pain that is not related to the normal menstrual cycle can be a cervical cancer symptom. Many women describe them ranging from a dull ache to sharp pains that can last hours. It can be mild or severe.
- Pain during urination: Bladder pain or pain during urination can be a symptom of advanced cervical cancer. This cervical cancer symptom usually occurs when cancer has spread to the bladder.
- Bleeding between regular menstrual periods, after sexual intercourse, douching, or pelvic exam: Bleeding after sexual intercourse, douching, or pelvic exam can be cervical cancer symptoms. This is due to the irritation of the cervix during these activities. While a healthy cervix may have a very small amount of bleeding, many conditions may cause bleeding after activities like sex.
Types of Cervical Cancer
There are two major types of cancer that develop from the cervix.
- Squamous Cell Cancers : Squamous cell cancers arise from the squamous epithelium that covers the visible part of the cervix. Squamous cell cancers are unique because there is a well established progression through premalignant changes before a cancer develops. These premalignant changes are easy to detect by a simple screening test called the Pap test.
- Adenocarcinomas: Adenocarcinomas arise from the glandular lining of the endocervical canal.
Each of these major types has several subtypes that may require special treatmentAbout 85% of cervical cancers are squamous cell cancers and the remainder adenocarcinomas.
Causes of Cervical Cancer
The cause of cervical cancer is unknown. Human papilloma virus or HPV is considered to have a strong assosiation with cervical cancer. There are many different types of HPV. It is sometimes called the genital wart virus as some types of HPV cause genital warts. In fact, the types that cause warts are not the types that cause cervical cancer. HPV is passed on from person to another through sexual contact. Women who get cervical cancer have had past infections with HPV. High risk types of HPV can cause changes in the cells covering the cervix that make them more likely to become cancerous in time. But most women infected with these viruses do NOT develop cervical cancer. So other factors must also be needed.
Screening and Diagnosis of Cervical Cancer
- Pap smear test:
A Pap smear is an examination under the microscope of cells scraped from the tip of the cervix. Doctors do this by putting an instrument called a speculum inside vagina and then scraping the cervix with a small brush. They put the brush and cells into a small pot of liquid and send it to the laboratory for examination. Cervical screening is not a test for cancer, but it is a test to check the health of the cervix. Most women’s test results show that everything is normal. But in some, the test will show some changes in the cells of the cervix.
Most of these changes will not lead to cervical cancer and the cells will go back to normal on their own. In some cases, the abnormal cells need to be treated to prevent them becoming a problem later. It is a major mistake to treat it on the basis of an abnormal Pap test without a diagnosis. An abnormal Pap test is not a diagnosis. It is only an abnormal screening test that must be evaluated.
The major benefit of the Pap test is to detect changes on the cervix before they become cancerous. These premalignant changes are referred to as dysplasias or as intraepithelial neopl asias. They are easily and effectively treated. If untreated, the abnormal cells may convert to cancer cells, which may spread in various stages into the cervix, the upper vagina and the pelvic areas and to other parts of your body. Cancer or precancerous conditions that are caught at the pre-invasive stage are rarely life-threatening and typically require only outpatient treatment. Most guidelines suggest beginning screening at age 21, and some recommend starting within three years of becoming sexually active, or no later than age 21
- Liquid based cytology:
Liquid based cytology (LBC) is a way of preparing cervical samples for examination in the laboratory. The sample is collected in a similar way to the Pap smear, using a special device (spatula) which brushes cells from the neck of the womb. Rather than smearing the sample onto a microscope slide as happened with the Pap smear, the head of the spatula, where the cells are lodged, is broken off into a small glass vial containing preservative fluid, or rinsed directly into the preservative fluid. The sample is sent to the laboratory where it is spun and treated to remove obscuring material, for example mucus or pus, and a representative sample of the remaining cells is taken. A thin layer of the cells is deposited onto a slide. The slide is examined in the usual way under a microscope by a cytologist. The reduction in inadequate rates from using LBC is of considerable benefit to women in terms of reducing anxiety, uncertainty and the need for repeat tests.
Inadequate samples are those where no result can be issued and include those where blood or other matter in the sample makes it impossible to see the cells properly. In these cases, women are invited back for a second test. The number of inadequate test results has fallen from over 9 per cent before the introduction of LBC to 2.5 per cent in 2009 so fewer women now needs a second test. A faster turnaround time in the laboratory also means that women get their results more quickly.
- Hybrid Capture II Test:
The Pap smear test alone does not tell if the cells will progress to cancer or not. The Hybrid Capture II HPV test tells if treatment is essential for women or not. It is a DNA based test that provides information about 13 types of HPV virus that might be the agent of infection of cervical cells. If the Pap smear and this test both show abnormal results, doctors can conclude the presence of precancerous cells. The HPV DNA test isn’t a substitute for regular Pap screening, and it’s not used to screen women younger than 30 with normal Pap results. Most HPV infections in women of this age group clear up on their own and aren’t associated with cervical cancer.
- Colposcopy:
A colposcopy is a special way of looking at the cervix. It uses a light and a low-powered microscope to make the cervix appear much larger. This helps your health care provider find and then biopsy abnormal areas in your cervix. Colposcopy is done to detect either cancer of the cervix or changes that may lead to cancer at an early stage. This procedure is most often done when you have had an abnormal Pap smear. It may also be recommended if you have bleeding after sexual intercourse. Colposcopy may also be done when your doctor sees abnormal areas on your cervix during a pelvic exam. These may include:
- Any abnormal growth on the cervix, or elsewhere in the vagina
- Genital warts or HPV
- Irritation or inflammation of the cervix (cervicitis)
The colposcopy may be used to keep track of HPV, and to look for abnormal changes that can come back after treatment.
- Loop Electrosurgical Excision Procedure (LEEP):
This process competes with Conization for popularity. Some physicians say that this test will replace the other one. The test involves the use of an electrode put inside the cervix to remove abnormal cells from the cervix and endo-cervical canal. A high frequency electric current is running through the wire. This technique can also be used as a treatment method.
Above tests help pin point the condition of cells and thus, if necessary, appropriate treatment can be started.
- Magnetic resonance imaging (MRI)
This test uses magnetism to build up pictures of the organs in your abdomen. It is very good at imaging the tissues of the pelvis where the cancer is. MRI is painless, and the magnetism is harmless. You will be asked to lie down inside a large metal tube that is open at both ends. You will probably have an injection, to help show up blood vessels. The test may take up to an hour. The tube makes some people feel claustrophobic (afraid of being in a small space).
- Computerised tomography (CT) scan
A CT scan is a type of x-ray that gives a cross-sectional picture of organs and other structures (including any tumours) in your body. CT scans are usually done at a hospital or a radiology clinic. It takes about 30 to 40 minutes to complete this painless test
- A positron emission tomography (PET)
A positron emission tomography (PET) scan can check to see if cancer has spread to other parts of the body. You will have an injection of a glucose solution containing a very small amount of radioactive material. The scanner moves around you, detecting the radioactive material in the glucose solution. Cancer cells show up as areas where glucose is being used by actively growing cells.
Treatment of Cervical Cancer
Treatment of cervical cancer begins with seeking regular medical care throughout your life. Regular medical care allows your health care professional to best evaluate your risks of developing cervical cancer, perform routine Pap smear screening, and promptly order further diagnostic testing as needed. These measures greatly increase the chances of detecting cervical cancer in its earliest, most curable stage. This stage is called cervical dysplasia, a precancerous condition that is 100% treatable.
The goal of cervical cancer treatment is to permanently cure the cancer or to bring about a complete remission of the disease. Remission means that there is no longer any sign of the disease in the body, although it may recur or relapse later. Cervical cancer treatment plans use a multifaceted approach and are individualized to the type of cancer and stage of advancement; your age, medical history, and coexisting diseases or conditions; and other factors.
Surgery for Cervical Cancer
- Cone Biopsy (Conization)
If the abnormal area can’t be seen properly with the colposcope, you may have a cone biopsy. This is done under a general anaesthetic, and you may need an overnight stay in hospital.
A small cone-shaped section of the cervix, which is large enough to contain the abnormal cells, is removed for examination under a microscope by a pathologist. If there is just a very small growth of cancer cells (microinvasive cancer), the cone biopsy may remove it all so that no further treatment is needed. Even if the cone biopsy has not removed all of the cancer cells, it’s still helpful for your diagnosis, as it will help the doctors to decide on the right type of treatment for you.
After the cone biopsy a gauze pack, like a tampon may be placed in your vagina to prevent bleeding. This is usually removed within 24 hours. You may also have a thin tube, called a catheter, put into your bladder so that you can pass urine while the vaginal pack is in place. It’s normal to have some light bleeding for a few days after a cone biopsy. Sometimes a cone biopsy can make the cervix slightly weaker, which may increase the risk of miscarriage during pregnancy. In this situation, miscarriage can often be prevented by putting a stitch into the cervix during pregnancy to strengthen it. Your doctor can discuss this with you in more detail if you are concerned about possible future pregnancies.
- Hysterectomy
A hysterectomy (removal of the uterus but not the ovaries) is not often performed for cervical cancer that has not spread. It may be done in women who have repeated LEEP procedures.
Treatment for more advanced cervical cancer may include:
- Radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina.
- Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed.
Radical Trachelectomy
For some very early cervical cancers, it is possible to have a radical trachelectomy. In this operation, your surgeon will try to remove all of the cancer, but leave the internal opening of the cervix. This is then stitched closed, leaving a small opening to allow the flow of your period to escape. The idea is that the stitch will support a pregnancy until the baby can be born by caesarean section. This operation can only be done if you have a small stage 1 cervical cancer. If surgeon finds that the cancer has spread further, you may need to have a hysterectomy after all. Your surgeon may also need to remove some lymph nodes from around your womb. This is usually done with a laparoscope (so it is sometimes called keyhole surgery).
Radiotherapy
Radiotherapy may be given for larger tumours contained in the cervix and it’s usually given if the cancer has spread beyond the cervix and is not curable with surgery alone. Radiotherapy may also be used after surgery if there is a high risk that the cancer may come back. It is often given in combination with chemotherapy (chemoradiation).
Treatment with radiotherapy may last for 5–8 weeks. Your cancer specialist (clinical oncologist), who plans your treatment, can discuss this treatment in detail with you.
External Radiotherapy
External radiotherapy is normally given as an outpatient, as a series of short daily treatments. High-energy x-rays are directed from a machine at the area of the cancer. The number of treatments will depend on the type and size of the cancer, but the whole course of treatment for early cancer will usually last a few weeks.
Before each session of radiotherapy, the radiographer will position you carefully on the couch and make sure that you are comfortable. During your treatment you will be left alone in the room, but you will be able to talk to the radiographer who will be able to see you from the next room. Radiotherapy is not painful but you do have to lie still for a few minutes during treatment. The treatment will not make you radioactive and it’s perfectly safe for you to be with other people, including children, afterwards.
Internal radiotherapy (Brachytherapy)
Internal radiotherapy (Brachytherapy) gives radiation directly to the cervix and the area close by. It’s often given following external beam radiotherapy.
To give internal radiotherapy, applicators (specially designed tubes) which give the radiation are placed into your vagina, close to the cervix. If the cervix has been removed during surgery, the tubes are placed at the vaginal vault which is at the top of the vagina. Internal radiotherapy may be given as low dose rate treatment or high dose rate treatment. Both low dose rate and high dose rate treatment give the same total dose of radiotherapy but over different time periods.
Low dose rate treatment
Low dose rate treatment is given as an inpatient over a few days using a machine which feeds small radioactive balls of caesium into the applicator tubes. One type of machine which gives this treatment is known as Selectron. The applicators are put into your vagina or womb during a short anaesthetic and gauze packing is used to stop them moving about. This can be uncomfortable so painkillers are often given.
The applicators are usually left in place for one or two days. The radioactive balls (sources) can be withdrawn into the machine when people come into the room. This is to keep the dose of radioactivity to visitors and nurses as low as possible. Visitors are usually restricted and children are not encouraged to visit while you’re having your treatment. You will be asked to stay in bed to make sure that the applicators stay in the right position during the treatment. For the same reason, you will have a urinary catheter in place. This is a small tube (catheter) which is passed into your bladder and which drains your urine into a collecting bag.
The safety measures and visiting restrictions might make you feel isolated, worried and depressed at a time when you might want people around you. If you have these feelings, it’s important to tell someone so that you can get some support. It might also help to take in plenty of reading material, an MP3 player and things to keep you occupied while you’re in isolation. You only need to be in isolation while the applicators are in place. Once they are removed the radioactivity disappears and it’s perfectly safe to be with other people.
The applicators will be removed by one of the doctors or nurses and this may be a bit uncomfortable (you will have painkillers beforehand). Sometimes sedation or gas and air (entonox) may be given to make it easier for you.
High dose rate treatment
With high dose rate treatment a machine (microSelectron)containing a radioactive source of iridium or cobalt is used to give a higher dose of radioactivity over a few minutes. Before the treatment you will have an anaesthetic so that the doctors can place the applicators through your vagina and into your womb or vaginal vault. Once the tubes have been inserted they are connected to the machine that passes the radioactive sources into the tubes. When the treatment is finished the tubes are removed. Treatments may need to be repeated several times, a few days apart, and may be given as an inpatient or outpatient. This treatment does not need a tube (catheter) in the bladder to drain the urine, but a catheter may be needed when x-ray pictures are taken during the planning of the treatment.
Pulsed Dose Rate Brachytherapy
This is a new method of giving Brachytherapy which is only available in some specialist centers. In this treatment the applicators stay in place for the same length of time as low dose rate treatment, but the radiation dose is given in pulses rather than as a continuous low dose.
Side effects of Radiotherapy
Chemotherapy
This is the treatment of cancer with anti-cancer drugs. The aim is to destroy all cancer cells while doing the least possible damage to normal cells. The drugs work by stopping cancer cells from growing and reproducing themselves. Chemotherapy is usually given to women with more advanced cancer or together with radiotherapy. You will probably have chemotherapy through a vein. You may need to stay in hospital overnight or you may be treated as a day patient. This depends on the drugs you are given and how you are feeling. You will probably have a number of treatments, usually six, every three to four weeks over several months. This depends on the disease and other treatments being used. You will have blood tests before your next treatment to make sure your body’s normal cells have had time to recover. The side effects of chemotherapy vary according to the drugs used. Nausea, fatigue, hair loss etc. are some common side effects. These side effects are temporary, and steps can often be taken to prevent or reduce them. There are effective medications to prevent many of the side effects. Chemotherapy may also cause periods to stop, either temporarily or permanently, causing premature menopause.
Combined radiotherapy and chemotherapy
A combination of radiotherapy and chemotherapy is used to treat cervical cancer. Trials have found that women with invasive cervical cancer have better rates of survival when they have chemotherapy that includes the drug cisplatin along with radiotherapy. Combined radiotherapy and chemotherapy can cause more side effects than radiotherapy alone. The side effects include a reduced number of white blood cells (leucopoenia), nausea and vomiting. These are temporary and can be treated.
Stages and Treatment Options
If a patient has cancer of the cervix, the doctor will order more tests to find out if the cancer cells have spread to other parts of the body. This process is called staging. Knowing the stage of the disease helps the doctor plan treatment. The following stages are used to describe cancer of the cervix:
Stage 0 or carcinoma in situ (dysplasia): Carcinoma in situ is a precancerous condition. Abnormal cells are found only in the first layer of cells of the lining of the cervix and do not invade the deeper tissues of the cervix. Treatment at this stage may be one of the following:
- Conization
- Laser surgery
- Loop electrosurgical excision procedure (LEEP)
- Surgery to remove the cancerous area, cervix, and uterus (total abdominal or vaginal hysterectomy) for those women who cannot or no longer want to have children
Stage IA: Stage IA cancer involves the cervix but has not spread to nearby tissue. A very small amount of cancer that is only visible under a microscope is found deeper in the tissues of the cervix. Treatment may be one of the following, depending on how deeply the tumor cells have invaded the normal tissue:
- Surgery to remove the cancer, uterus, and cervix (total abdominal hysterectomy). The ovaries may also be taken out (bilateral salpingo-oophorectomy), but they are usually not removed in younger women.
- Conization.
- For deeper tumors (3-5 millimeters), surgery to remove the cancer, the uterus and cervix, and part of the vagina (radical hysterectomy), along with the lymph nodes in the pelvic area (lymph node dissection).
- Internal radiation therapy.
Stage IB: Cancer involves the cervix but has not spread nearby. A larger amount of cancer is found in the tissues of the cervix. Treatment may be one of the following, depending on how deeply the tumor cells have invaded the normal tissue:
- Internal and external radiation therapy
- Radical hysterectomy and lymph node dissection
- Radical hysterectomy and lymph node dissection with or without chemotherapy
- Radiation therapy plus chemotherapy
Stage IIA: Cancer has spread to nearby areas but is still inside the pelvic area. Cancer has spread beyond the cervix to the upper two thirds of the vagina. Treatment may be one of the following:
- Internal and external radiation therapy
- Radical hysterectomy and lymph node dissection
- Radical hysterectomy and lymph node dissection with or without radiation or chemotherapy
- Radiation therapy plus chemotherapy
Stage IIB: Cancer has spread to nearby areas but is still inside the pelvic area. Cancer has spread to the tissue around the cervix. Treatment may be internal or external radiation therapy plus chemotherapy.
Stage III: Cancer has spread throughout the pelvic area. Cancer cells may have spread to the lower part of the vagina. The cells also may have spread to block the tubes that connect the kidneys to the bladder (the ureters). Treatment may be internal or external radiation therapy plus chemotherapy.
Stage IVA: Cancer has spread to other parts of the body, such as the bladder or rectum (organs close to the cervix). It is unusual for cervical cancer to reach this stage. If it does, treatment may be internal or external radiation therapy plus chemotherapy.
Stage IVB: Cancer has spread to distant organs such as the lungs. It is unusual for cervical cancer to reach this stage. If it does, treatment may be radiation to relieve symptoms caused by the cancer plus chemotherapy.
Prognosis
Cervical cancer can be effectively treated when detected early. For women whose cancer has progressed further, a cure is often still possible. For other women, treatment can keep the disease under control for long periods of time. Recovery is differs with every patient. It depends on the type and stage of cervical cancer patient is in and also the amount of treatment the patient has undergone. You will need to have regular check-ups with your specialist. These may include blood tests and physical examinations. If the cancer recurs in the pelvis, Radiation therapy combined with chemotherapy and Chemotherapy can be done to relieve symptoms caused by the cancer.
Benefits of treatment of Cervical Cancer
The goal of cervical cancer treatment is to permanently cure the cancer or to bring about a complete remission of the disease. The benefits of cervical cancer screening are substantial. Pre-cancer conditions are completely curable when followed up and treated properly. The chance of being alive in 5 years (5-year survival rate) for cancer that has spread to the inside of the cervix walls but not outside the cervix area is 92%.
Screening reduces cervical cancer incidence and mortality. Surgery is used for smaller cancers that have not spread far beyond the cervix. Radiation therapy uses high-energy radiation to kill cancer cells and shrink tumors. Chemotherapy drugs are used to kill cancerous cells. In most cases, chemotherapy works by stopping cancer cells from growing or reproducing and kills the cells. Long-term studies show that the vast majority of patients continue to remain free of cervical cancer after receiving treatment with Brachytherapy. Cure rates are often found to improve with the treatment of cervical cancer.
Treatment of Cervical Cancer in India
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Low Cost Treatment of Cervical Cancer in India Low cost of treatment and tremendous cost saving opportunities has resulted in an increase in the number of American and European patients considering the option of going abroad to seek out for high quality and low cost medical care and India is their first choice. Treatment of Cervical Cancer in India is extremely cost effective. The quality of treatment is unparalleled. For Patients travelling to India from a different country accommodation and transportation is always a concerned. India offers some of the world’s best hotels with 3-5 star rating and still low rates.
