Cervical cancer usually develops slowly within a few years. Before real cancer cells develop, the cervix is exposed to changes in the cellular level called dysplasia or precancer. These changes, which can be detected by the pathologist in a pap smear test, range from mild (CIN1), moderate (CIN2) or severe (CIN3) dysplasia or cervical intraepithelial neoplasia. If these precancerous forms are not treated, they tend to spread deeper into the tissue and turn into cancer. These cells can progress deeper into the vagina, rectum, or bladder tissues, and may eventually lead to metastasis in other parts of the body.
Cervical cancer occurs in various forms. Most common is squamous cell carcinoma, accounting for 85% to 90% of cervical cancers. Other forms include combination cancers such as adenocarcinomas and adenosquamous carcinoma. Some strains of human papillomavirus (HPV), a virus transmitted during sexual intercourse, are responsible for the formation of cervical cancer.
It is the second most common type of cancer in women below the age of 45 years. 85% of these cancers occur in low- or middle-income countries. The most commonly seen in Haiti from countries 94/100 000. One woman dies of cervical cancer every two minutes in the world. In the world of cervical cancer, 528,000 new cases of cervical cancer are detected annually and half of them are fatal.
Cervical cancer, especially in the early stages, usually does not give any symptoms. Therefore, it is very important that you go to a doctor for regular screening.
When symptoms occur, they may include:
• Pain or bleeding during or after sexual intercourse
• Pelvic pain following pelvic examination
• abnormal, odorous discharge from the vagina
• Blood stains or light bleeding other than normal menstrual period
These symptoms can also be caused by cervical cancer or some other serious diseases. For this reason, a doctor should immediately evaluate the symptoms.
Risk, Prevention and Screening
Human papillomavirus (HPV) is the most important risk factor for cervical cancer. Researchers today think that more than 99% of cervical cancers are caused by HPV. HPV is a common virus that will infect more than two-thirds of sexually active women at some point in their lives. For more than 20 years, papilloma viruses have been known to cause cervical dysplasia or precancerous forms. More recently, DNA in these viruses has been found to be present in almost all cervical squamous cell carcinomas (the most common type of cervical cancer). Infection with HPV does not necessarily mean cervical cancer. The immune system removes this virus from the body by 90% in 12-18 months after being infected with this virus. 10% of the HPV can not be cleaned, 5-10 years in the cervix, pre-cancer and cancer can be seen in such formations.
Other risk factors for cervical cancer include:
• sexual intercourse at an early age
• Having many sex partners
• Smoking (cigarettes produce chemicals that can damage cervical cells and make them more vulnerable to infection and cancer)
• Using birth control drugs
• HIV infection (reduces body’s ability to fight HPV infection and early forms of cancer)
Women can reduce the risk of developing cervical cancer by avoiding these known risk factors. In women without these risk factors, cervical cancer rarely develops.
According to the American Cancer Society, all women can help protect themselves against HIV and other sexually transmitted diseases by allowing their partners to use condoms; however, condoms do not provide full protection against HPV. Using a condom will probably reduce the infection rate by about 70%, because HPV (unlike HIV) can be spread through physical contact with any infectious area in the body.
Guidelines for screening
We advise women to have their first cervical cancer screening at the age of 21, regardless of the age of first sexual intercourse.
Women up to 30 years old
For women up to 30 years of age, we recommend having a cervical cytology test (pap-smear) every two or three years.
Women over 30
For women aged 30 and over, we recommend one of the following three scanning options:
• We recommend having a cervical cytology test (Pap smear test) every 3 years.
• Cytology and HPV DNA testing can be performed together.
If both come negative, screening can be done every five years.
The Pap smear test is used for screening cervical cancers and cervical precancer. In the early stages, cervical cancer usually does not cause symptoms.
Pap smear test: In this test, cell samples are taken from the cervix to examine abnormal or precursor changes in the membrane covering the cervix during vaginal examination.
Colposcopy: If the results of the Pap smear test are not normal, check your cervix using a magnifying lens (colposcopy) and collect cell samples (biopsy) to determine if cancer is present.
If examinations exhibit precancerous changes in cells such as abnormal tissue development or in situ carcinoma, the tissue can be removed or treated using the laser or LEEP technique. If the examinations show invasive cancer, your doctor will ask you for more tests to determine the size of the cancer. These tests may include:
Physical examination: This examination includes rectum and anus examination.
Cytoscopy: Evaluation of the bladder using an illuminated camera.
Rectosigmoidoscopy: Visual examination of the rectum with a camera to determine if there is cancer.
Positron emission tomography (PET) screening: This scan can detect whether the cancer is spread out of the cervix or surrounding lymph nodes.
Computed tomography scan: Can show whether the cancer is spread.
Pyelogram: A special dye is injected intravenously and an x-ray of the urine system is drawn.
Stages of cervical cancer
Stage 0 or in situ carcinoma: Stage 0 cancer is pre-invasive cancer, and abnormal cells appear only in the first layer of the cervical membrane cells.
Stage I: Stage I cancer is limited to the cervix. Depending on the size of the tumor and how deep the cancer is spreading, It can be classified as Stage IA1, IA2, IB1 or IB2.
Stage II: Stage II cancer spread out of the uterus but did not affect the pelvic side walls or the upper third of the vagina. It can be classified as Stage IIA or IIB.
Stage III: In stage III, the cancer exceeds the pelvic wall or the lower third of the vagina, or leads to dilation of the uterus causing kidney problems. Cancer cells can be classified as Stage IIIA or IIIB according to whether they spread to the side wall of the pelvis.
Stage IV: Stage IV is spread to the bladder or rectum. Class IVA or IVB.
Gynecological oncologists, medical oncologists and radiation oncologists act together to create the appropriate treatment for your needs. Most stage I and II cases of cervical cancer will have the option of surgery or combination of chemotherapy and radiotherapy. If your cancer is more advanced, your doctor may recommend a combination of treatments that may include surgery, chemotherapy, and radiotherapy.
Types of surgery
Surgeons can perform many procedures according to the stage of the disease and the patient’s needs. The following procedures may be recommended according to the stage of the disease:
Cervical cone biopsy (conization): Using a scalpel or cautery, your surgeon takes a cone-shaped part of the cervical tissue, where the abnormality is present. (Figure 2)
Laser surgery: A thin laser is used from intense light source to kill abnormal cells. Surgeons usually do this surgery to clear their precancer cells.
Loop electrosurgical excision procedure (LEEP): In this procedure, the surgeon uses a cable loop to pass the electrical current that cuts the diseased tissue through the cervix. (Figure 3)
Cryosurgery: Your doctor freezes cancerous and precancer cells.
Simple hysterectomy: In this procedure, the surgeon takes the cervix and the uterus.
Radical hysterectomy: In this procedure, the surgeon takes the cervix, the uterus, the surrounding tissue (parametrium) and the 1-2 cm portion of the vagina.
In the radical trachelectomy approach, which means that the surgeon takes the cervix, an alternative to radical hysterectomy is presented. This procedure is performed in patients whose tumors are limited to the cervix. Therefore, a large part of the uterus (the upper part of the uterus known as the fundus) can be protected. This method is decided according to the patient’s desire to have children. In young patients, this method can be applied in patients who want to have a child if the disease is limited in the cervix.
All of these surgical methods can be performed by closed methods (laparoscopic and robotic). Thus, patients can be treated as soon as possible if they need radiotherapy and chemotherapy after surgery because they have recovered in a very short time.
Lymphadenectomy: In the case of cervical cancer, when the disease is outside the cervix, the first area of spread is the adjacent lymph nodes. For this reason, lymphadenectomy in the lymph nodes in this area is called lymphadenectomy to understand that the disease is spreading out of the cervix at the cellular level.
Exenteration: The surgeon has spread to other organs close to the cervix, in advanced cancer or after previous treatment; however, if the body does not spread to the distal areas of the uterus, it may suggest exenteration. This includes the removal of a part of the uterus, cervix, lymph nodes and possibly the bladder, vagina, rectum and colon.
Reconstructive surgery: This method is often used in advanced cases of cervical cancer, reconstruction (reconstruction) may be necessary for some parts of the vagina, bladder, pelvic floor and hip.
Radiotherapy: Radiotherapy is usually one of the most effective treatments for cervical cancer at any stage of its development.
Intensity-adjusted External radiotherapy (IMRT): This external radiotherapy is minimized by high-dose radiation applied to healthy tissue around the tumor. This form of treatment is five weeks until patients receive radiation therapy every day for short periods.
Brachytherapy: Brachytherapy is a procedure that involves placing radioactive material inside your body. Brachytherapy is one type of radiation therapy that’s used to treat cancer. Brachytherapy is sometimes called internal radiation. Brachytherapy allows doctors to deliver higher doses of radiation to more-specific areas of the body, compared with the conventional form of radiation therapy (external beam radiation) that projects radiation from a machine outside of your body. Brachytherapy may cause fewer side effects than does external beam radiation, and the overall treatment time is usually shorter with brachytherapy.
Chemotherapy: In chemotherapy, anti-cancer drugs are administered intravenously or orally to destroy cancer cells. High doses of chemotherapy are applied when the cancer spreads out of the tumor or relapses after the first treatment. Studies have shown that low-dose chemotherapy when combined with radiotherapy increases survival in women with advanced cervical cancer.
Reconstructive surgery: A gynecological oncologist and plastic surgeon move together to restore anatomy and function as much as possible through reconstructive surgery. This teamwork is particularly important in radical cancer surgery, which includes surgical reconstruction (reconstruction) as part of your treatment plan.
Reconstructive surgery procedures include:
Restructuring the vagina: Reconstruction of the vagina structure after radical cancer surgery can be achieved by shifting tissue (skin grafts) from the patient’s legs or abdomen.
Reconstruction of vital organs: Your surgeon can regenerate vital organs (such as the bladder, vagina, or pelvic floor) taken to treat advanced cancer or that are damaged during radiotherapy. For example, for your bladder reconstruction, your surgeon can create a pouch that holds your urine inside the body, eliminating the need for an external collection bag.
Pelvic floor reconstruction: Pelvic floor reconstruction can correct pelvic sagging or urine or fecal defect.
There are two vaccines that provide protection from two of the most dangerous types of human papillomavirus (HPV), the cause of many cervical cancer cases (HPV 16 and 18). These vaccines can prevent up to 70% of cases of cervical cancer, but they cannot prevent infection due to any virus causing cervical cancer. In order to be effective, the vaccine should be administered at 2 or 3 doses within 6 months. The World Health Organization (WHO) recommends vaccination of girls aged 9-13 years, that is, vaccination before sexual intercourse. After this age group, according to FDA data, up to 45 years of age, vaccination can be protected against vaccination against HPV types. The vaccine does not cure HPV infection or HPV-associated cancer. It is a non-therapeutic protective acid. It should be noted, however, that even if the vaccine is administered, a regular Pap-Smear test against cervical cancer should continue.