Cervical Cancer

Contents

Cancer of the Cervix

Cancer of the cervix is one of the more common cancers found in women. The cervix is the lowest most part of the uterus (womb), the part that protrudes into the top of the vagina. The cervix connects the uterus to the vagina.

Cancer of the cervix is the most preventable of all cancers that occur in women and is probably one of the most preventable of all cancers. This prevention is by the regular performance of Pap smears. The National Health & Medical Research Council (NHMRC) guidelines recommend second-yearly Pap smears from the time a woman becomes sexually active to the age of 70 years.

Cervical cancer grows slowly and goes through a pre-cancerous phase which lasts for several years before cancer actually develops. This pre-cancerous phase is best diagnosed with a Pap smear which can pick up the presence of these pre-cancerous cells developing on the cervix. This pre-cancerous phase has no symptoms. In recent years the traditional Pap smear has been improved with what is called liquid based cytology, e.g., ThinPrep®. There is increasing evidence that liquid based cytology is superior to the traditional Pap smear.

A separate information document covers the topic of pre-cancer of the cervix, also called CIN.

Early stages of cervical cancer are usually without symptoms, although if they do occur, post-coital bleeding, that is bleeding after intercourse, is one of the more common symptoms. Any woman who has noticed bleeding from the vagina after sexual intercourse or has noticed a blood stained discharge from the vagina between her periods should see her family doctor without delay.

The prognosis (chance of recovery/survival) and choice of treatment depends on the stage (see below) of the cancer and the patient's general health.

Prevention:

The vast majority of cervical cancers are caused by some members of the Human Papilloma Virus (HPV) group. There are well over 100 different viruses in this group which cause a range of problems from simple skin warts through pre-cancerous lesions to cancers. The recent development of HPV vaccines (Gardasil® & Cervarix®) against some of these viruses should lead to a marked reduction in the future incidence of cervical cancer.

HPV Immunisation with Gardasil® is now being provided free of charge to girls at school (12-18 years) and young women under 27 years.

This will probably turn out to be one of the greatest advances in the prevention of cancer in the world.

Management of Cervical Cancer

Once cancer of the cervix is found (diagnosed), more tests will be done to find out if the cancer is still limited to the cervix or whether some of the cancer cells have spread to other parts of the body. This process is called staging. To recommend and plan treatment the doctor needs to know the stage of the cancer.

Staging

This involves some or all of the following:

    * a physical/pelvic examination. This may be done under an anaesthetic
    * a cystoscopy to look inside the bladder with a small telescope.
    * Chest x-ray
    * X-ray CT (Computerised Tomography) scan of pelvis and abdomen

    *MRI (Magnetic Resonance Imaging or PET (Positron Emission Tomography) scan
    * Blood tests - full blood count, clinical biochemistry & liver function tests.

The following staging system is used world wide

Stage 0

This is also known as cervical pre-cancer or Cervical Intraepithelial Neoplasia (CIN). This is not true cancer but a pre-cancerous stage where the abnormal cancer cells are still limited to the superficial skin and do not invade the deeper tissues of the cervix.

Stage I

Cancer is limited to the cervix itself.

    stage IA: a very small amount of cancer is present only visible with a microscope.
    stage IB: a larger amount of cancer is present and can be seen with the naked eye.

Stage II

Cancer has spread to nearby areas immediately next to the cervix.

    stage IIA: cancer has spread beyond the cervix to somewhere in the upper 2/3 of the vagina.
    stage IIB: cancer has spread to the tissues beside the cervix but not as far as the side of the pelvis.

Stage III

Cancer has spread further than in stage II but is still limited within the pelvis.

    stage IIIA: cancer has spread to the lower 1/3 of the vagina.
    stage IIIB: cancer has spread to the side of the pelvis.

Stage IV

Cancer has spread to other parts of the body.

    Stage IVA: cancer has spread to the bladder or rectum.
    Stage IVB: cancer has spread to areas outside the pelvis.

Recurrent

Recurrent cancer means that the cancer has come back (recurred) after it has been treated. It may come back in the cervix, the pelvis or elsewhere.

not curable.
Treatment depends on the stage of disease and the general health of the patient. The following presumes that the treatment is aimed at curing the patient and not just at palliation.

Three kinds of treatment may be used either singularly or in combination, depending on the circumstances.

    * surgery (an operation to remove the cancer)
    * radiotherapy (the use of high energy x-rays to kill the cancer cells)
    * chemotherapy (the use of drugs to kill cancer cells)

How is Cancer of the Cervix Treated

All cases of cervical cancer can be treated. The decision between surgery, radiotherapy, chemotherapy or some combination of these treatments will depend on a number of factors including the type of the cancer, the stage of the cancer and any medical co-morbidities in the patient.

Treatment by Stage

Stage O

This may be treated by any one of laser, local excision (LLETZ), diathermy, cone biopsy or simple hysterectomy.
In this practice stage O is usually treated by local excision (LLETZ) or cone biopsy although simple hysterectomy is used in some women who have completed their family.

Stage I & some early Stage IIA

While this may be treated by either surgery or radiotherapy, surgery is usually recommended in this practice especially in younger patients because it has less long term complications. The operation is called a radical hysterectomy and radical pelvic lymphadenectomy. This operation involves removing the uterus, cervix, a small amount of the upper vagina, the tissue on either side of the cervix (parametrium) and the lymph glands or nodes from along the blood vessels in the pelvis.

After the pathology report comes back further treatment may be recommended. Generally, if the tumour is large or aggressive, or close to the edges of the surgery, or if there is tumour in the lymph nodes, then further treatment will be recommended with radiotherapy and chemotherapy.

Most cervical cancers are squamous cell carcinomas (SCC) and the ovaries do not need to be removed unless the tumour is of a special type called an adenocarcinoma. If this is the case then it may be recommended that the ovaries be removed because there have been some reports that there was a 3-5% risk of the cancer being in one or other of the ovaries. If this is the case and the ovaries are not removed then cure of the cancer is unlikely.

Stage IIA, IIB, IIIA, IIIB.

In the past these patients are treated with radiotherapy. However, in an increasing number of patients the use of chemotherapy is also recommended as recent studies would indicate that this results in an improved prognosis.

Stage IVA

Treatment needs to be very carefully individualised as some patients can be treated by surgery. This operation (a pelvic exenteration) involves removing the uterus and cervix as described above in radical hysterectomy, however the affected bladder or segment of bowel are also removed. If this sort of surgery is contemplated then it will be explained in detail to the patient. Otherwise these patients are treated with radiotherapy with or without chemotherapy.

Stage IVB

These patients need to have their treatment planned carefully and on an individualised basis. They may be treated with radiotherapy or chemotherapy.

Recurrent Cervical Cancer

If the cancer has come back then treatment is available. If the recurrent cancer is in the centre of the pelvis and there is no evidence of disease outside the central pelvis, then surgery may be possible. This would involve removing the lower bowel (rectum) &/or bladder along with the cervix, uterus and vagina (a pelvic exenteration).

If the cancer is not limited to the centre of the pelvis then treatment is usually by radiotherapy &/or chemotherapy.

It is important to understand that if cancer of the cervix spreads to, say, the liver or the lung, it is not then cancer of the liver or the lung. It is cancer of the cervix in the liver or the lung.

If a patient's cancer has recurred it is NOT re-staged. A patient who originally had Stage I cancer who develops a recurrence, say in the lungs some time later, does NOT then have Stage IV cancer; they have recurrent metastatic Stage I cancer.

Follow-up after Treatment

When treatment is over, regular follow-up check ups are instituted. The frequency of these visits is determined by the doctor, however, the following would be a common follow-up pattern:

For the first two years: every three months

For the next three years: every six months

From five years onwards: every year.

At these visits a physical examination, including a pelvic examination is performed along with a smear from the top of the vaginal in some patients at their anniversary visit.

Summary

With the use of Pap smears cancer of the cervix is the most preventable form of cancer.

All stages of cervical cancer can be treated although the likelihood of cure (survival rate) depends to a large extent on the stage of the cancer.

Cancer of the cervix is best managed by a Certified Gynaecological Oncologist.