Carcinoma (cancer) of the cervix is predominantly squamous cell cancer. After the breast cancer, carcinoma of the cervix is second most common malignant diseases in women. However, cervical cancer is now less common than it used to be before because of early diagnosis and detection of cell changes by pap smear test. It occurs more commonly in women above 40-50 years of age group.
There are several different types of cervical cancer. Most of these cancers are squamous cell carcinomas and the remaining are adenocarcinoma or mixed adenosquamous carcinomas. Adenocarcinomas begin in mucus producing glands and are often HCV infected. Most cervical cancers, if not detected and treated early it may spread to pelvic lymph nodes and local recurrence is common. The main responsible factor of developing cervical carcinoma is the influence of sexual intercourse at early age.
The preventive measures include regular pelvic examinations and pap smear tests atleast twice a year for all women, especially elder women past childbearing age which decrease the chances of death from cervical cancer from 1 in 250 to 1 in 2,000. The preventive counselling must encourage delaying first intercourse in early hood, avoidance of HPV infection, participating in safer sex only, cessation of smoking cigarettes, and receiving HPV immunization.
Stages of carcinoma of cervix
Stage 0: carcinoma in situ, cervical intra epithelial neoplasia (CIN) which means pathological changes eg. Metaplasia and dysplasia.
Stage I: the lesion is invasive but confined to the cervix usually at the squamocolumnar junction.
Stage II: The lesion extends beyond the cervix to he upper vagina and parametrium, but not to the pelvic side walls.
Stage III: The lesion reaches onee or both pelvic side walls and the ower third of the vagina.
Stage IV: In this stage the spread involves the bladder and the rectum; there may also be distant metastasis.
Aetiology and risk factors for cervical cancer
- Cause is unknown
- Sexual activity: multiple ex partners
Early age (yonger than 20 years) at first sexual
(Exposes the vulnerable young cervix to
Potential viruses from partner)
- Sex with uncircumcised males
- Sexual contact with males whose partners have had cervical cancer.
- Early childbearing
- Exposure to human papilloma virus type 16 and type 18.
- HIV infection or other immunodeficiency disease.
- Smoking and passive smoking
- Exposure to diethylstilbestrol (DES) in utero.
- Family history of cervical cancer
- Low socio-economic status that may be related to early marriage and early childbearing.
- Nutritional deficiencies such as folate, beta-carotene and vitamin C levels are lower in women with cervical cancer than in women without the cancer.
- Chronic cervical infection
- Obesity or overweight status
Early cervical cancer rarely shows any symptoms or it may go unnoticed by.
- A thin watery vaginal discharge often noticed after intercourse or douching.
- When symptoms such as discharge, irregular bleeding or pain after sexual intercourse occur, the disease may be advanced.
- Advanced condition should not occur or develop of all women have access to gynaecological care.
- In advance cases, the vaginal discharge gradually increases and becomes watery and finally, finally dark and foul-smelling from necrosis and infection of the tumor.
- The bleeding which occurs at irregular intervals between periods or after menopause may be slight enough to spot the undergarments and usually occurs after mild trauma or pressure.
- As the disease progresses, the bleeding may persist and increase with leg pain, dysuria, rectal bleeding and edema of the extremities signal advanced disease.
- As the cancer advances, it may invade the tissues outside the cervix, including the lymph glands anterior to the sacrum and in one third of the patients with invasive cervical cancer, the disease involves the fundus.
- If the disease progresses, it often produces extreme emaciation and anemia, usually accompanied by fever due to secondary infection and abscess, and by fistula formation.
- Early detection is necessary as the rate for women with more advanced stages of cervical cancer decreases dramatically where the survival rate for in situ cancer is 100%.
- Diagnosis may be made on the basis of abnormal pap smear results, followed by biopsy results identifying severe dysplasia.
- Carcinoma in situ is technically classified as severe dysplasia and is defined as cancer that has extended through the full thickness of the epithelium of the cervix, which is referred as preinvasive cancer.
- In early stages, the cancer is found microscopically by pap smear. In later stages, pelvic examination may reveal a large, reddish growth or a deep, ulcerative lession which may be reported as spotting or bloody discharge by patient.
- Signs and symptoms are evaluated, and x-rays, laboratory tests and special examinations such as punch biopsy, cone biopsy, and colposcopy are performed.
- Depending on the status of the cancer, Other tests and procedures may he performed to determine the extent of disease and appropriate treatment.
- Such tests may include
- Dilation and curettage (D &C)
- Computed tomography (CT)
- Magnetic resonance imaging (MRI)
- IV urography
- Positron emission tomography
- And barium ×-ray studies.
When precursor lesions are diagnosed by colposcopy and biopsy, careful monitoring by frequent pap smears or conservative treatment is possible. Conservative treatment is may consist of monitoring, cryotherapy (freezing with nitrous oxide) or laser therapy. A loop electocautery excision procedure (LEEP) may also be used to remove abnormal cells. In this procedure, a thin wire loop with laser is used to cut away a thin layer of cervical tissue under local anaesthetic agent. Another procedure called a cone biopsy or conization (removing a cone shaped portion of the cervix) is performed. If Preinvasive cervical cancer occurs when a woman has completed childbearing, a simple hysterectomy is usually recommended. If the woman has not completed childbearing and invasion is less than 1mm, conization may be sufficient. Frequent follow-up examinations are necessary to monitor for recurrence.
Treatment of the invasive cervical cancer depends on the stage of the lesions, the patient’s age and general health, and the judgement and experience of the physician. Surgery and radiation treatment (intracavitary and external) are most often used.
- Total hysterectomy- is removal of the uterus, cervix and ovaries
- Radical hysterectomy- is removal of the uterus, ovaries, fallopian tubes, proximal vagina and bilateral lymph nodes through an abdominal incision.
- Radical vaginal hysterectomy – vaginal removal of the uterus, ovaries, fallopian tubes and proximal vagina
- Bilateral pelvic lymphadenectomy- is the removal of the common illiac, external illiac, hypogastric and obturator lymphatic vessels and nodes.
- Pelvic exenteration- is the removal of the pelvic organs, including the bladder or rectum and pelvic lymph nodes, and construction of diversional conduit, colostomy and vagina.
- Radical trachelectomy- is removal of the cervix and selected nodes to preserve childbearing capacity in woman of reproductive age with cervical cancer.
Surgery is often complex because it iis performed close to the bowel, bladder, ureters and great vessels. Complications can be considerable and include pulmonary emboli, pulmonary edema, myocardial infraction, sepsis and fistula formation, most common in the first 18 months.
Radiation, which is often part of treatment to reduce recurrent disease, may be delivered by an external beam or by brachytherapy. The area to be irradiated and dose of radiation are determined by stage, volume of tumor and involvement of lymph nodes. Treatment can be administered daily or 4-6 weeks followed by one or two treatments of intracavitary radiation. Interstitial therapy may be used when vaginal placement has become impossible because of tumoror stricture.
Platinum-based agents are being used to treat advanced cervical cancer. They are often used in combination with radiation therapy, surgery or with combination of both.