Cervical Cancer

  • Occurs in cells of cervix, the narrow part of the lower uterus that connects to the vagina (referred to as the neck of the womb).
    • Affects the entrance to the womb.
  • Various strains of the human papillomavirus (HPV) play a role in causing most cervical cancer.
  • Occurs when the cells of the cervix grow abnormally and invade other tissues and organs of the body.
  • When this type of cancer is invasive, it affects the deeper tissues of the cervix and may spread to other parts of the body.
    • Most notably the lungs, liver, bladder, vagina and rectum.
  • Cervical cancer is slow growing.
    • Progression through precancerous changes provides opportunities for prevention, early detection, and treatment.
    • One of the most preventable types of cancer.

Statistics

  • The cancer that causes the largest number of deaths among women in developing countries.
  • 2nd most common cancer among South African women.
  • 1 in every 42 women in South Africa will be diagnosed with cervical cancer.
  • Incident rate of cervical cancer in South Africa is reported between 22.8 and 27 per 100 000 women compared to the global average of 15.
  • Annually there are 5 743 new cases reported with 3 027 associated deaths in South Africa.
  • 99% of cervical cancers are associated with HPV.

Signs and Symptoms

Early stage cervical cancer generally produces no signs/ symptoms

  • For this reason, regular screening through Pap and HPV tests can help catch precancerous cell changes early and prevent the development of cervical cancer.

Signs and symptoms of more-advanced cervical cancer

  • Unusual bleeding.
  • Vaginal bleeding after intercourse, between periods/ after menopause.
  • Watery, bloody vaginal discharge that may be heavy/ have a foul odour.
  • Pain and discomfort during intercourse.

Advanced cervical cancer

  • Constipation
  • Blood in urine
  • Loss of bladder control
  • Bone pain
  • Swelling of one of your legs
  • Severe pain
  • Side/ back pain caused by swelling in kidneys
  • Changes to bladder and bowel habits
  • Loss of appetite
  • Weight loss
  • Tiredness/ lack of energy
  • Kidney failure due to urinary tract/ bowel obstruction (when cancer is advanced)

Diagnosis

  • Pap testing is the most typical screening procedure.
  • If abnormal cells are detected a colposcopy procedure is performed.

Colposcopy

  • Uses a lighted microscope to examine the external surface of the cervix during a pelvic exam.
  • If abnormal areas are noted, a small tissue sample/ biopsy is taken for examination by a pathologist to look for precancerous changes or cancer.
  • Procedure requires no special anaesthesia.
    • Similar to having a Pap smear in terms of discomfort.
  • Transformation zone of the cervix cannot always be visualised well during a colposcopy.
  • One of the following procedures may be performed.

Endocervical curettage or scraping:

  • Sample of cells taken from interior canal of cervix.

Conization

  • Removal of cone shaped portion of cervix around cervical canal.
  • Tissue removed with thin loop of wire heated by electrical current.
    • Called a loop electrosurgical excision procedure (LEEP).
      • Performed in doctor’s office with local anaesthetic.
    • Another option is having the cone-shaped tissue fragment removed in an operating room under general anaesthetic.
      • Referred to as cold knife conization.
    • After the conization/ biopsy procedure the pathologist studies the tissues to determine if precancerous changes/ cancer is present.
      • Referred to as cervical intraepithelial neoplasia grades 1 to 3.
    • If cancer is present, depending on size and extent of tumour, other tests might be done to help determine the extent to which the tumour has spread.
      • Additional tests include chest x-rays, CR/ MRI imaging studies.
  • The following tests may also be necessary.

Cystoscopy – examination of the interior of the urinary bladder using a thin, lighted scope

Proctoscopy – examination of rectum

Examination under anaesthesia allows the doctor to perform a manual pelvic examination without causing pain to help determine the degree of spread of cancer within the pelvis

Risk Factors

  • Risk can be reduced by having screen tests and receiving a vaccine that protects against the HPV infection
  • HPV
    • This is a sexually transmitted disease
    • More than 100 different types of HPV can occur
    • At least 13 of which may cause cervical cancer
  • Many sexual partners
    • The greater your number of sexual partners, and the greater your partner’s number of sexual partners, the greater your chance of acquiring HPV
  • Early sexual activity
    • Having sex at an early age increases your risk of HPV
  • Other sexually transmitted infections (STIs)
    • Having other STIs, such as chlamydia, gonorrhoea, syphilis and HIV/AIDS, increases your risk of HPV
  • A weak immune system
    • You may be more likely to develop cervical cancer if your immune system is weakened by another health condition and you have HPV
  • Smoking
    • Smoking is associated with squamous cell cervical cancer
    • Chemicals in cigarette smoke interact with cells of cervix, causing precancerous changes that may over time progress to cancer
    • Risk of cervical cancer in cigarette smokers is 2 – 5 times that of the general population
  • Birth control pills
    • Long-term use of some common contraceptive pills slightly raise a woman’s risk

Treatment

  • Depends on many factors including stage of cancer when diagnosed.
  • Treatment options include surgery, radiotherapy, chemotherapy and targeted therapy.
  • Different kinds of doctors may be involved in the treatment team
    • Gynaecologic oncologist – physician that specialises in treating cancers of the female reproductive organs, including surgery to remove scars.
    • Radiation oncologist – physician who uses radiation to treat different kinds of cancer.
    • Medical oncologist – specialist in the use of chemotherapy and other medical therapies to treat cancer.
  • Surgery
    • Performed to remove cancer, especially early-stage tumours
    • Hysterectomy may be performed.
      • Other procedures that preserve ability to carry a pregnancy can be done in younger women with small tumours.
    • Cone biopsy – removal of the inside of the cervix where most tumours begin.
    • Trachelectomy – removal of upper vagina and cervix.
      • Both used to remove small tumours to preserve fertility.
    • Pelvic exenteration – removes uterus, surrounding lymph nodes, parts of other organs surrounding cancer.
      • With more advanced cancer.
  • Radiation therapy
    • External beam radiation therapy – radiation therapy administered from outside source of radiation.
    • Brachytherapy – radiation therapy that involves insertion of radioactive sources near tumour for fixed period.
      • Can be used together.
    • If radiation therapy is given as the main treatment, it is often combined with chemotherapy.
    • Side effects include fatigue, diarrhoea, skin changes, nausea, vomiting, irritation of bladder, vaginal irritation and discharge.
      • Sometimes menstrual changes/ early menopause if ovaries exposed to radiation.
    • Chemotherapy
      • Recommended together with radiation.
      • May be given before/ after radiation.
      • Chemotherapy drugs commonly used for cervical cancer.
      • May be treatment of choice for cervical cancer that has come back after treatment.
      • Side effects include nausea, fatigue, vomiting, hair loss, mouth sores.
    • Targeted therapy
      • Refers to drugs specifically developed/ targeted to interrupt cellular processes that promote growth of cancer cells.
      • Inhibits ability of tumours to make new blood vessels which is required for tumour growth.
      • Used for advanced cervical cancer.