Cervical cancer is the second most common cancer in Indian women (As per Globocan 2012) .
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.
What is Cervix?
The 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 isthe ectocervix. It is about 2-3 cms in length.
More women in India die from cervical cancer than in any other country.
Around 1.23 lakh new women are diagnosed with cervical cancer in India and 67,500 women die of cervical cancer in India every year (Globocan 2012) .
The incidence of cervical cancer is higher in rural areas when compared to cities .
Risk Factors 
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.
(I) Primary Prevention: It is designed to prevent the disease from occurring in the first place.
Indian Academy of Pediatrics (IAP) recommendations on HPV vaccination:
Vaccine does not guarantee complete protection against cervical cancer. Cervical screening tests are still important as:
Duration of protection of vaccine:
The duration of vaccine protection is unclear. Current studies indicated that the vaccine is effective for at least 5 years. Ongoing studies are investigating the long term efficacy of the vaccine.
VACCINATION IS NOT A REPLACEMENT FOR CERVICAL CANCER SCREENING
Currently, there are no guidelines on HPV vaccination in our country.
(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 . 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.
The Pap (Papanicolaou) test is a method that has been used for over 60 years to detect potentially pre-cancerous and cancerous changes in cells of the cervix.
Pap smear is a simple and painless test. An instrument called a speculum is introduced into the vagina to visualize the cervix. The health care provider will then use a special stick or brush to take a few cells from the surface of and inside the cervix. The cells are placed on a glass slide and sent to a lab for cytologic testing. The Pap test is done in married women above 21 years and should be repeated once in every 3 years. If this test is combined with HPV test (for women above 30 years of age), then the duration of screening can be increased to 5 years.
Other tests used for screening of cervical cancer
HPV test is a laboratory test used to check the presence of DNA or RNA for certain types of HPV. Cells are collected from the cervix and are checked to find out if an infection is caused by a type of HPV that is linked to cervical cancer . This test may be done using the sample of cells removed during a Pap test. This test is not recommended in women aged below 30 years as HPV infection is very common in this age and may be spontaneously cleared within 2 years.
Visual inspection of the cervix, using acetic acid (VIA) or Lugol’s iodine (VILI) is also used as a screening test to find precancerous lesions. Such procedures do not need laboratories and transport of specimens, require very little equipment and provide women with immediate test results. A range of medical professionals-doctors, nurses, or professional midwives-can effectively perform the procedure, provided they receive adequate training and supervision.
Abnormal Pap tests
Abnormal Pap test results usually do not mean you will always have cancer. Most often there is a small problem with the cervix. If results of the Pap test are unclear or show a small change in the cells of the cervix, your doctor may repeat the Pap test immediately, in 6 months or a year, or run more tests. Some abnormal cells will turn into cancer. Treating abnormal cells that don’t go away on their own can prevent almost all cases of cervical cancer. If you have abnormal results, talk to your doctor about what they mean. If treatment is needed, it can be done early enough to prevent cancer before it develops. Treatment is often done in an out patient department (OPD). If the test finds more serious changes in the cells of the cervix, the doctor will suggest more tests. Results of these tests will help your doctor decide on the best treatment.
The Pap smear is a simple test to collect a small sample of cells from the cervix which helps to diagnose precancerous and cancerous conditions of the cervix. It also aids in diagnosing infections and inflammation of the lower reproductive tract.
Who should get the Pap test done?
As per the International recommendations, the age to initiate screening is 21 years.
Women who are 30 years and above should undergo a Pap test once in every 3 years until the age of 65 years. If this test is combined with HPV test, then the duration of screening can be increased to 5 years.
Women who do not routinely require Pap test
When should the Pap test be done?
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
Following should be avoided 48 hours before the test:
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 not usually painful.
Results of Pap test
A Pap test result may be reported as normal or abnormal.
If the test report is normal, this means no abnormal or cancerous cells have been found in the smear taken.
Abnormal Pap test results usually do not mean that the woman has cancer. Most often there is a small problem with the cervix. 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 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.
Signs and Symptoms
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.
If any of the screening tests (Pap test, VIA, HPV test) are found to be positive, further testing may be necessary to determine whether the changes are cancerous. A colposcopy may be performed and/or a small sample of tissue (biopsy) will be obtained from the cervix
The process to find out the extent 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.
Different stages of cervical cancer
Three types of treatment 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.
Treatment of pre-cancerous lesions may include the following: Removal or destruction of the part of the cervix affected by disease.
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.
Stage II Cervical Cancer
Treatment of stage II cervical cancer may include the following:
Stage III Cervical Cancer
Treatment of stage III cervical cancer may include internal and external radiation therapy combined with chemotherapy
Stage IV Cervical Cancer
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