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Cervical Cancer

Anatomical facts:

The cervix is a part of the female reproduction system.  It is at the mouth of the womb and dilates during childbirth to allow the baby to safely pass through the canal from the womb to the world. Cervical cancer has become one of the first cancers to become preventable with the help of a vaccine, the HPV vaccine. The FDA confirmed the approval of a vaccine that combats infection against two main types of HPV, or the Human Papillomavirus in the year 2006[1]. These two viruses are responsible for almost 70% of all cervical cancer cases reported all over the world. Based on the results of the clinical trials conducted for the vaccine, the drug showed 100% effectiveness in the prevention of all precancerous changes occurring in the cervix due to HPV infections.

diagram of female reproductive orgrans - cervical cancer is cureable

Cervical cancer and its detection:

Till the early 1950’s, cancer of the cervix was responsible for the death of more women than any other type of cancer found in the United States of America. Since then, the mortality rates have decreased significantly, by almost over 70%. This has been due to the awareness of the vaccine and implementation of the specialized cancer detection exams known as the Pap smear exams.

In the Pap smear test, a swab is used to remove the cells from the cervix of a woman and then these cells are examined with the help of a microscope. It is a fairly simple exam and can be performed by any professional clinician when a woman appears for her annual checkup.

The Pap smear exam is one of the most effective methods for the detection of precancerous changes seen in the cervix, which are known as the CIN, or cervical intraepithelial neoplasia. If these changes are not treated immediately, they may rapidly progress into the formation of a tumor of the cervix. According to the American Cancer Society, there are almost 11,000 cases of cervical cancer reported each year. Prior to the use of the anti-cancer vaccine almost 3,700 deaths resulted from cervical cancer. Out of these, nearly 50% of cervical cancer cases were reported from females ranging from 35 to 55 years of age. It is a fact that cervical cancer can also affect older women. Nearly 20% of all cervical cancer cases are seen in females over the age of 65.

HPV and its role in Cervical Cancer:

A large number of all cervical cancer cases are known to have occurred following HPV infections. HPV is a specific class of viruses which is comprised of more than one hundred viruses that can be transferred from one person to the other via sexual contact. Most adults have experienced an HPV infection during some part of their lives. However, cervical cancer is only associated with specific, rare strains of the HPV, which means that a majority of the women who have been infected with HPV will not develop any cancerous changes or tumors.

A greater risk of developing cervical cancer comes from having multiple sexual partners, or by having sexual intercourse with a partner who previously has had multiple partners. Another significant factor that substantially contributes to the development of cervical cancer is excessive smoking and numerous complete term pregnancies.

A serious risk factor is the lack of Pap smear tests from routine checkups for the detection of cervical cancer. It has been noted that the majority of cervical cancer cases are reported from women who have never undergone cancer screening in their lives, and typically come from low socio-economic backgrounds. People with this situation are affected more often because of the lack of access to adequate health care and medical facilities.

Types of Cervical Cancers:

Cervical cancer has two main types, namely squamous cell carcinoma and adenocarcinoma. Nearly 85% of all cervical cancer cases are those of squamous cell carcinoma while 15% of them are adenocarcinomas. In terms of prognosis and treatment, both types are similar. If detected at an early stage, cervical cancer can be removed with minor surgery and less invasive procedures which allow the surgeons to remove only the affected cells and tissues while preserving the healthy portion of the cervix.

Treatment:

A simple hysterectomy is a procedure, which is effective in early stages of cancer, in which the uterus and the cervix are removed. In some cases, if the cancer is detected during its initial stages, invasive procedures may not be required at all to treat the patient. In these cases, radiation therapy itself is effective for the removal and destruction of cancerous tissue.

In cases of advanced stage cancer, some of the treatment options used for the removal of cancerous tissue include radiation therapy, surgical procedures and chemotherapy. The surgery used for the destruction of cancerous tissue in case of advanced cervical cancer is known as radical hysterectomy and involves the complete removal of the uterus, the cervix and the upper portion of the vagina. If the cancer is wide spread and highly advanced, it may require the removal of the fallopian tubes, the ovaries and the pelvic lymph nodes for complete treatment. Metastatic cancers, that is cancers that have spread to affect other organs, are managed with the help of radiation therapy and chemotherapy in order to improve the quality of life of the patient.

Cervical Cancer Treatments

The treatment of cervical cancer depends on many factors that include the stage of cancer, general health and history of patient, age and the desire to have children in the future. There are many kinds of treatment available and may be applied alone or in combination.

Types of treatment that may be used are:

  • Surgery
  • Radiotherapy
  • Chemotherapy
  • Targeted therapy
  • Hyperthermia

Surgery

There are different kinds of surgical procedures to treat cervical cancer. These include:

Cryosurgery or Cryotherapy:  This is not exactly a treatment for cervical cancer. It is mostly used to remove precancerous cells in the cervix. The affected region is frozen to kill abnormal cells.  It is done by using a special instrument called cryoprobe through which liquid nitrogen is passed. It cools the metal probes inserted in the cervix, which helps to kill the affected cells.

Conization:  This refers to the excision of a cone shaped tissue from the cervix for pathological examination.

Loop electrosurgical excision procedure (LEEP): The LEEP is a new procedure for removing the tumor. A low voltage electrical current is delivered through a thin wire which removes the tumor.

Laser surgery: A laser beam, which precisely cuts off the tumor, is used in this form of therapy.

Simple hysterectomy

In this surgery, the cervix and uterus are removed, removing the cancer. This surgery is used only when the cancer has been detected at an early stage. A laparoscopic surgery is suggested for patients at an early stage of cervical cancer. A small camera and special instruments are used for this purpose. Small incisions are made in the belly for such surgery.

Radical hysterectomy

In this surgery, the cervix, uterus, part of the vagina and nearby lymph nodes are removed. This surgery is used when the cancer has invaded by more than 3 mm into the cervix.

Radical trachelectomy

In this surgery, the cervix and its surrounding tissue are removed. This surgery, along with the removal of nearby lymph nodes, is preferred for girls who are young and the disease is detected early. Since the uterus is kept intact, the patient may have children later.

Bilateral Salpingo-Oophorectomy  

Both ovaries and the fallopian tubes are removed in this surgery. This type of surgery is sometimes used in combination with a hysterectomy.

Pelvic exenteration: Patients with advanced stage cervical cancer can be treated with pelvic exenteration. All organs of the pelvic cavity including cervix, vagina and ovaries, together with surrounding lymph nodes are removed. Artificial openings are used for removal of excretory products, which are then collected in a plastic bag. Plastic surgery is done to re-create the vagina.

Chemotherapy

Chemotherapy is the treatment in which drugs are used to get rid of the cancer. There are many drugs available to treat cervical cancer. Some of them are cisplatin, carboplatin, 5-FU and paclitaxel. The most commonly used is cisplatin, which is often given in combination with radiotherapy or other chemotherapy drugs. But, most chemotherapeutic drugs cause a lot of side effects including infertility.

Chemotherapy may be given as a primary treatment for cervical cancer or can be given before surgery to make the treatment more effective.  In some cases chemotherapy is given at a low dose together with radiation therapy. This is done to enhance the effect of radiation therapy. This combination is called chemoradiation. Such drugs used with the radiation therapy are called “radiation sensitizers”.

Drugs are given to patients at a very high dose if the patient is diagnosed at a late stage. This only helps to prevent rapid spread of the cancer all throughout the body and increase the life-span of patients by reducing the symptoms.

Radiation therapy

Radiation therapy uses high energy X rays to kill cancer cells. Radiation therapy is often used with chemotherapy for more effective treatment of cervical cancer. This can be done in two ways:

External radiation therapy: A beam of radiation from a machine outside the body is aimed at the affected site of the patient’s body.

Internal radiation therapy or brachytherapy: Radioactive substance sealed in small pellets is placed near the affected region. Cancer cells are killed by the radiations emitted from the radioactive substances.

Early stage cervical cancers can be treated with brachytherapy alone. However, for the treatment of advanced stage patients external radiation therapy may also be used in combination with brachytherapy.

Targeted therapy

Targeted therapy refers to the use of certain drugs that inhibit the growth of cancer cells by blocking the effect of defective genes and proteins. Side effects are much less when targeted therapy is used.

Hyperthermia

It is a kind of treatment in which high temperature is used to kill cancer cells of a particular region. It has been used in some cases after radiation therapy to reduce chances of recurrence of cervical cancer and increase the life span of the patient.

Clinical trials
Clinical trials refer to those kinds of treatment which are not yet standardized. It is a part of research that aims to develop better strategies for the treatment of cancer. The patients may willingly participate in clinical trials, but cure is not guaranteed.

References

Rodríguez Villalba S, Díaz-Caneja Planell C, Cervera Grau JM. Current opinion in cervix carcinoma. Clin Transl Oncol. 2011 Jun;13(6):378-84.

Undurraga M, Loubeyre P, Dubuisson JB, Schneider D, Petignat P. Early-stage cervical cancer: is surgery better than radiotherapy? Expert Rev Anticancer Ther. 2010 Mar; 10(3):451-60.

Lutgens L, van der Zee J, Pijls-Johannesma M, De Haas-Kock DF, Buijsen J, Mastrigt GA, Lammering G, De Ruysscher DK, Lambin P. Combined use of hyperthermia and radiation therapy for treating locally advanced cervical carcinoma. Cochrane Database Syst Rev. 2010 Jan 20; (1):CD006377

This article was originally published on 7/12/2014 and last revision and update of it was 9/14/2015.