Cervical Cancer Awareness

Globally, cervical cancer is one of the most common cancers among females. In low- and middle-income countries second most common cancer in incidence among women and the third most common in terms of mortality. Women 35 to 44 years old are most likely to get it, 15% of new cases are in women over age 65, especially those who haven’t been getting regular screening.

ANATOMICAL CONSIDERATIONS

The cervix  is the lowermost part of the uterus, is cylindrical-shaped structure ,The intravaginal part, the ectocervix, projects into the vagina.

Cervix is visualized easily and sampled, can be treated by freezing and burning with little or no anesthesia.

Mainly two types of cancer of the cervix — squamous cell carcinomas and adenocarcinomas. About 80% to 90% are squamous cell carcinomas, while 10%-20% are adenocarcinomas.

EARLY DETECTION AND PREVENTION OF CERVICAL CANCER

Cervical cancer is a long-term outcome of persistent infection of the lower genital tract by one of about 15 high-risk HPV types. Of the estimated 530 000 new cervical cancer cases annually, HPV 16 and HPV 18 account for 71% of cases; while HPV types 31, 33, 45, 52, and 58 account for another 29% of cervical cancer cases  Nearly 90% of incident HPV infections are not detectable within a period of 2 years from the acquisition of infection and persist only in a small proportion.One-tenth of all infections become persistent, and these women could develop cervical precancerous lesions.

Cervical cancer can be control by two major ways: (1) prevention by HPV vaccination; and (2) screening for precancerous lesions.

Primary prevention of cervical cancer with HPV vaccination

As a preventive strategy HPV vaccination should target women before starting of sexual activity, focusing on girls aged 9–14 years.

Currently three prophylactic HPV vaccines are available for the prevention of premalignant lesions and cancers affecting the cervix, vulva, vagina, and anus caused by high-risk HPV type. 

Bivalent vaccine targeting HPV16 and HPV18; a quadrivalent vaccine targeting HPV6, HPV11,HPV16 and HPV18; and a nonavalent vaccine targeting HPV types 31, 33, 45, 52, 58 HPV 6, 11, 16, and 18. The last two vaccines also help to prevents anogenital warts caused by HPV 6 and 11. For girls and boys aged 9–14 years, a two-dose schedule 0 and 5–13 months  is recommended. 15 years and above, and for immunocompromised patients irrespective of age, the recommendation is for three doses at 0, 1, 6 months.

Secondary prevention of cervical cancer by early detection and treatment of precancerous lesions

Cervical cancer screening has been successful in preventing cancer by detection and treatment of precursor lesions, namely, high-grade cervical intraepithelial neoplasia (CIN 2 and 3) and adenocarcinoma in-situ (AIS).

For cervical screening strategies tests includes conventional cytology (Pap smear), liquid-based cytology and HPV testing, and,visual inspection with acetic acid (VIA).

Primary HPV screening, ( higher sensitivity and negative predictive value) allows extended screening intervals or even a single lifetime screening.

Pap test guidelines:

Cervical cancer screening should begin at age 25 years, regardless of sexual history.

• For women aged 25 to 29 years, screening is recommended every 3 years with  Pap test.
• For women 30 years and older, co-testing with Pap and HPV should be done every 5 years, or Pap test alone every 3 years.
• Routine Pap testing should be discontinued (stopped) in women who have had a total hysterectomy for benign conditions and who have no history of CIN (cervical intraepithelial neoplasia) grade 2 or higher.
• Cervical cancer screening can be discontinued at age 65 in women who have 2 consecutive normal co-test results or 3 consecutive normal Pap test results in the past 10 years, with the most recent normal test performed in the past 5 years.

Adequately treated women for CIN grade 2 or higher will need to continue screening for 20 years, even if it takes them past the age of 65.

These recommendations are not for women who have HIV, are immunocompromised, have a history of DES in utero exposure, and have not been adequately screened.

Women with abnormal Pap test or who have been treated for an abnormal Pap test will have a different scheduled

SYMPTOMS AND CAUSES

• Watery or bloody vaginal discharge which may be heavy and can have a foul odor.
• Vaginal bleeding which can be after intercourse or exercise, between menstrual periods, or after menopause.
• Menstrual periods that may be heavier and longer than normal

              In advance stages, symptoms may include:

• Difficult or painful urination, sometimes with blood in urine.
• Diarrhea, or pain or bleeding from the rectum upon defecation.
• Fatigue, loss of weight and appetite.
• A general feeling of illness.
• Dull backache or swelling in the legs.

              Risk factors include:

• An irregular screening history
• HPV Infection
• Sexual History: Females who begin having sexual intercourse before the age of 16
• Have multiple sexual partners
• Smoking: Cigarette 
• HIV Infection
• Take birth control pills, especially for longer than 5 years
• Have a weakened immune system
• Have a sexually transmitted disease (STD)

DIAGNOSIS AND TESTS

Diagnosis of cervical cancer mostly can be done by pelvic examination and Pap smears. For an accurate diagnosis, examine the cervix and a tissue sample of any apparent abnormality for biopsy.

Precancerous changes

On the surface of cervix any unusual changes in cells are called squamous intraepithelial lesions SIL. These are precancerous cells. They might not become cancerous or invade deeper layers of tissue for months or years, low-grade lesion, may not need treatment, 

LEEP, conization, cold knife conization, cryosurgery (freezing), cauterizationor laser surgery can be used to destroy the precancerous area with little damage to nearby healthy tissue.

follow-up exam and Pap smear after cryocautery or laser ablation is required to make sure all the precancerous cells are gone.

Different Types of Cervical Cancer

There’s more than one kind of cervical cancer.

• Squamous cell carcinoma: It’s found in up to 90% of cases
• Adenocarcinoma
• Mixed carcinoma

Invasive cancer

Tests to see whether it’s spread and how far.

• Chest X-ray
• Blood tests 
• An intravenous pyelogram IVP 
•  Cystoscopy to check bladder and urethra
• Colposcopy 
• Proctosigmoidoscopy and barium enema 
• CT, MRI, or PET scans lymph nodes

MANAGEMENT AND TREATMENT

The treatment team for cervical cancer will include a gynecologic oncologist, Radiation oncologist, and medical oncologists. Cervical cancer treatment depends upon many factors including the stage of the disease, the age and general health of the woman, and her desire for future childbearing. The three main cervical cancer treatments are surgery radiation and chemotherapy. In advance stages, or in recurrence radiation and chemotherapy both may be used to treat cancer.

There are two kinds of radiation treatment:

Brachytherapy- Device loaded with radioactive pellets placed into the vagina locally

External Radiotherapy- External device which beams radiation into the target areas

Surgery for cervical cancer include:

• Cone biopsy: Cone-shaped piece of tissue is removed from the cervix.
• Radical hysterectomy and pelvic lymph node dissection: The uterus, surrounding tissue called the parametrium, a small portion of the upper part of the vagina, and lymph nodes from the pelvis are removed.
• FERTILITY PRESERVING RADICAL HYSTERECTOMY can be done in young patient: Cervix and surrounding area parametrium and lymph nodes are removed.