Cervical Cancer

What is Cervix?

Cervical CancerThe cervix is the lower part of the womb also known as uterine cervix. The cervix connects the body of the uterus to the vagina(birth canal). The part of the cervix closest to the body of the uterus is called the endocervix. The part next to the vagina is the ectocervix. The cervix is about 2-3 cms in length.

What is cervical cancer?

Cervical cancer is the third most common cancer in Indian women (As per Globocan 2018) [1].

Cervical cancer is a preventable disease as it has a well defined, long pre-malignant phase which can be detected by regular screening tests and follow up. Unfortunately, most women in India are not aware about the screening.

Burden of the disease
More women in India die from cervical cancer than in any other country.

New case of cervical cancer in India: 96,322 every year [1].

Deaths due to cervical cancer: 60,078 [2].

Are you at risk? 

  • Persistent infection of the cervix with Human Papillomavirus (HPV)
  • Having many sexual partners
  • Husband having multiple sexual partners
  • Having first sexual intercourse at a young age
  • Giving birth to many children
  • Smoking
  • Due to HIV/AIDS, immunosuppressive drugs, transplant etc.

The presence of these risk factors does not imply that you will definitely acquire cancer. However, if you have one or more of these risk factors, it is advisable to consult your doctor.

How can it be prevented

  • (I) Primary Prevention: It is designed to prevent the disease from occurring in the first place.
    • Adopt safe sex practices (avoid multiple sexual partners).
    • Use of male condoms as barrier contraceptives to reduce the risk of HPV infection.
    • Timely treatment of reproductive tract infections.
    • There is evidence that circumcision for men may reduce the incidence of infection among sexual partners.
    • HPV vaccination: Prophylactic vaccines for cervical cancer target HPV 16 and 18, the most common oncogenic types of HPV responsible for cervical cancer. HPV vaccination is not effective against all oncogenic HPV types. Currently two vaccines, licensed globally are available in India; a quadrivalent vaccine (against HPV genotypes 6, 11, 16, 18) and a bivalent vaccine (against HPV genotypes 16, 18). The vaccine dose is 0.5 ml given intramuscularly, either in the deltoid muscle or in the antero-lateral thigh. It is available as a sterile suspension for injection in a single-dose vial or a prefilled syringe. The recommended age for initiation of vaccination is 9–14 years. Catch-up vaccination is permitted up to the age of 26 years.
      Females who have not been exposed to the HPV infection are likely to benefit more from the vaccine.

    Indian Academy of Pediatrics (IAP) recommendations on HPV vaccination[4]:

    • Only 2 doses of either of the two HPV vaccines for girls aged 9-14 years: does at internal of 6 months
    • For girls 15 years and older, and those with HIV/AIDS on chemotherapy or after organ transplant: does at 0, 1-2 and 6 months.

    Please Note:
    Vaccine does not guarantee complete protection against cervical cancer. Cervical screening is still important.

    Duration of protection of vaccine: currently unclear. Research is ongoing to look into.

    VACCINATION IS NOT A REPLACEMENT FOR CERVICAL CANCER SCREENING

    Currently, there are no guidelines on HPV vaccination in India.

    (II) Secondary Prevention: Secondary prevention aims at detecting the disease in its early stages (pre-cancers) through screening and to prevent its progression.

    Screening tests are done in apparently healthy women to diagnose changes in the cervix which are pre-cancerous and could develop into cervical cancer in future. If the abnormal tissue or cells are removed, the disease can be prevented from progressing to cancer [5]. Available screening tests for cervical cancer include Pap smear test, VIA (visual inspection with acetic acid), VILI (visual inspection with Lugol’s iodine) and HPV DNA test.

    Pap smear test

When should you consult a doctor?

  • Abnormal vaginal bleeding: Bleeding and spotting between periods, unusually longer or heavier periods, bleeding after menopause
  • Unusual or excessive vaginal discharge with foul smell
  • Vaginal bleeding after having sexual intercourse
  • Pain in the lower abdomen or pelvic pain
  • Pain during sexual intercourse

The presence of these signs and symptoms does not imply that you are suffering from cancer. However, if you have one or more of these, it is advisable to consult your doctor.

Are there test for early detection?

Screening Tests

The Pap smear is a simple test thatcollect a few cells from the cervix and help to diagnose  precancerous and cancerous conditions of the cervix. It also aids in diagnosing infections of the lower reproductive tract.

Who should get the Pap test done?

As per the International recommendations, women above the age of 21 years can get the pap test.

If you are 30 years and above Pap test should be done once in every 3 years till you turn 65 years of age. If this test is combined with HPV test, then the test may may be repeated every years.

Women who do not routinely require Pap test

  • Women aged less than 21 years and above 65 years
  • Women who had their womb removed for non-cancerous conditions

What is the right time for a Pap test?

The Pap test yields optimum results if scheduled between 10 to 20 days from the first day of menstrual period. The woman should not be menstruating at the time of test.

Preparation for Pap smear

You should avoid the following for 48 hours before the Pap test:

  • Intercourse
  • Douching of vagina
  • Vaginal medications
  • Vaginal contraceptives like creams/ jellies

Procedure

An instrument called a speculum is gently introduced into the vagina to visualize the cervix. There may be some discomfort or cramping during the procedure, but it is usually not painful.

  • A small wooden stick or spatula is used to gently scrape the surface of the lower part of the cervix to pick up cells.
  • A special brush, called a cytobrush is used to obtain cells from the inner part of the cervix.
  • The cells are placed on a glass slide, immediately fixed in ethanol and sent to laboratory for further processing and interpretation.

Results of Pap test

A Pap test result may be reported as normal or abnormal.

  • Normal Pap test

If the test report is normal, this means no abnormal or cancerous cells have been found in the smear taken.

  • Abnormal Pap tests

Abnormal Pap test results do not mean that the woman has cancer. If results of the Pap test are unclear or show a mild abnormality in the cells of the cervix, your doctor may repeat the Pap test in 6 weeks, in 6 months or a year, or run more tests. Treating abnormal cells that don’t go away on their own can prevent almost all cases of cervical cancer. Treatment of this abnormality is often done in an out-patient department (OPD). If the test findings suggest more severe abnormality in the cells, it is then confirmed by further diagnostic procedures:

Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas.

Biopsy: A sample of tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of cancer. A biopsy that removes only a small amount of tissue (punch biopsy) is usually done in the OPD.

Visual Inspection using Acetic acid (VIA) (lower part of womb)
Naked-eye visual inspection of the uterine cervix, after application of 5% acetic acid (VIA) provides simple test for the early detection of cervical precancerous lesions and early invasive cancer. The results of VIA are immediately available

How can it be diagnosed?

If any of your screening tests (Pap test, VIA, HPV test) are found to be positive, further testing may be necessary to determine whether the changes in cervix are cancerous. A colposcopy may be performed and/or a small sample of tissue (biopsy) will be obtained from the cervix

  • Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas.
  • Biopsy: If abnormal cells are found in a Pap test, the doctor may do a biopsy. A sample of tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of cancer. A biopsy that removes only a small amount of tissue is usually done in the out patient department (OPD). If a larger cone-shapedsample needs to be taken (cone biopsy), you may need to get admitted for a short period.
Treatment of pre-cancerous lesions may include the following: Removal or destruction of the part of the cervix affected by disease.

Invasive: Three types of treatment procedures are used to treat cervical cancer viz. surgery, radiotherapy and chemotherapy. These therapies may be given alone or in combination with one another. Treatment depends on the stage of the cancer, the type of tumor cells and a woman’s medical condition.

  • Cryosurgery: application of freezing probe to destroy abnormal or diseased tissue in the cervix for about 5 minutes.

 

  • Loop electrosurgical excision procedure (LEEP): procedure to remove abnormal and or cancerous cells in the cervix using a thin, low-voltage electrified wire loop that acts as a knife.

 

    • Laser surgery: Using a laser beam to burn the abnormal cells in the cervix.

 

    • Conization: Excision of a cone-shaped sample of tissue from the mucous membrane of the cervix by using cold knife or scalpel. This procedure requires hospital admission.

 

  • Hysterectomy: for women whose tumor cannot be completely removed by conization and who no longer want to have children.

 

The process to find out the spread of disease is called staging.

  • Stage 0 or Carcinoma in situ:  abnormal cells are found in the innermost lining of the cervix which may not be seen to naked eye.
  • Stage I: In this stage, cancer is limited to cervix only.
  • Stage II:  Cancer has spread beyond the cervix but not to the tissues that line the part of the body between the pelvic wall or to the lower third of the vagina.
  • Stage III:  Cancer has spread to the lower third of the vagina, and/or to the pelvic wall, and/or has caused kidney problems.
  • Stage IV: Cancer has spread to the bladder, rectum, or other parts of the body. 

Treatment of invasive cervical cancer

Stage I Cervical Cancer

Treatment of stage I cervical cancer may include surgery, chemotherapy and/or radiation therapy depending on the sub-stage, age and desire of the patient and preference of the treating physician.

  • Total hysterectomy with or without bilateral salpingo-oophorectomy
  • Modified radical hysterectomy and removal of lymph nodes.
  • Internal radiation therapy.
  • Radical hysterectomy and removal of lymph nodes.
  • Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
  • Radiation therapy plus chemotherapy.
  • A combination of internal radiation therapy and external radiation therapy

 

Stage II Cervical Cancer

 Treatment of stage II cervical cancer may  include either of the following:

  • Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
  • A combination of internal radiation therapy and external radiation therapy plus chemotherapy.
  • Radical hysterectomy and removal of lymph nodes.
  • Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.

Stage III Cervical Cancer

Treatment of stage III cervical cancer may include internal and external radiation therapy combined with chemotherapy

Stage IV Cervical Cancer

  • Radiation therapy to relieve symptoms caused by the cancer and improves quality of life (radiation therapy as palliative therapy).
  • Chemotherapy and targeted therapy (monoclonal antibodies). Chemotherapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life.
References

[1] Ferlay J, Soerjomataram I, Ervik M, et al. (2013) GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11.Lyon, France: http://globocan.iarc.fr. Accessed on 04 Sep 2014

[2] Kurkure AP, and Yeole BB. Social inequalities in cancer with special reference to South Asian countries. Asian Pac J Cancer Prev 2006;7:36-40
[3] Bosch FX, de Sanjosé S. Chapter 1: Human Papillomavirus and Cervical Cancer–Burden and Assessment of Causality. J Natl Cancer Inst Monogr 2003;31:3-13
[4] Vashishtha VM, Choudhury P, Kalra A, et al. Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years–India, 2014 and updates on immunization. Indian Pediatr. 2014 Oct; 51(10):785-800.
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[6] Moyer VA; U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012;156:880-91
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[8] Sankaranarayanan R, Budukh AM and Rajkumar R. Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bull World Health Organ 2001;79:954-62
[9] Shepherd JH. Cervical and vulva cancer: changes in FIGO definitions of staging. Br J Obstet Gynaecol 1996;103:405-6