Cervical Carcinoma

Cervix is the lower part of the female uterus. It is present in between the colon and the uterus below. In general its part of the woman’s womb.

Cervical cancer is the fourth most frequent cancer in women with an estimated 570,000 new cases in 2018 representing 6.6% of all female cancers. Cervical cancer is caused by a virus, Human papillomavirus, and it can be prevented by proper vaccination. Human papillomavirus vaccine had been introduced from the year 2006. It is to be given to women from the age of 9 to age 26, it is better to give before the first sexual intercourse.

This virus spread from one human to another by sexual intercourse either by, vaginal, oral or anal. If properly diagnosed, cervical cancer is one of the most preventable cancers with a survival rate of more than 90%. Screening programmes are available for human papilloma virus detection. Even though we know that cervix is a part of the uterus and women are the carriers and sufferers it is also important to know that men can carry the human papillomavirus and it can cause genital warts in them and a low chance of developing penile cancer.

Screening is a form of mass test that helps to recognize a particular link between a disease. To determine if a person harbours the virus, Visual Inspection with acetic Acid(VIA), Pap smear and HPV test are available Usually screening is done from age 21 to 65 years with a 3 years interval, it is not needed in people who have had a hysterectomy (a surgical removal of uterus).

VIA- Visual Inspection with acetic Acid is a screening test. Here the doctor or a nurse will take the patient in a private room and ask her to lie down on an examination table. A sterile speculum is introduced through the vaginal opening. A proper look at the cervix is done, to see if it is healthy or raw. Then a cotton swab stick that has been soaked in 3-5% of acetic acid is inserted and moved so that the acetic acid touches all surfaces. After 1 to 3 minutes interval the doctor/ nurse will have a look at the cervix, if there is no white patches or any bleeding then the person has a healthy cervix , if not then furthermore test are done.
VIA is usually carried out in a low income countries, it is affordable, feasible and uncomplicated. Results are seen soon after the procedure is carried out. If the results are negative then it should be carried out every 3 to 5 years from the last time of test.

Pap Smear is a painless and a quick screening test , also known as papanicolaou test. It is similar to VIA. Once the doctor makes the patient comfortable in the examination table, a sterilized speculum is introduced and a medical spatula is introduced into the body of the uterus. The spatula is moved around to collect cells and then moved out and smeared into a sterilized glass, then sent for cytology test. This procedure needs to be carried out by a professional, and the results are not immediate. The pathologist will check for abnormality of the cells, if they give any indication of cancer or not.

HPV DNA test is another confirming screening test, here a cotton swab or a small medical brush is introduced through the vagina into the cervix and moved around so that some cells are collected and preserved by a doctor in a container and sent for further testing in the laboratory. Compared to VIA and Pap smear, HPV DNA test is complicated and expensive.

An abnormal results from the screening the patient is referred to do colposcopy and a cervical biopsy

• Heavy menstrual flow

• In between menstrual bleeding

• Painful intercourse

• Pelvic pain

• Increased abnormal vaginal discharge with foul smell

• Genital warts

If these conditions are seen, consult a Gynaecologist , if he/ she finds any abnormality the patient will be referred to an oncologist.

• Early marriage, before the age of 18 years old

• Multiparity

• Multiple sexual partners

• Unprotected sexual intercourse

• Smoking

• Living in a poor environment ( such as slums, camps)

• HIV or someone who harbours HPV virus

• Long term contraceptive pills

There is already presence of vaccination to prevent Cervical Cancer, other than that practicing safe sex, and being in a monogamous relation, having regular screening tests should be sufficient. 4

Vaccination schedule: 5 Vaccination can be done either in 2 or 3 dosage. It is to be administered to patients from an early age of 9 to 14 years, two dosages are fine, the difference between the two dosage should be about 5 months.15 years to 45 years a person needs to get 3 dosage, 0, 1-2, and 6 months. We give vaccinations to both female and male patients, even though men do not have a cervix, it is to prevent the virus to cause warts and penile cancer. Before any vaccination it is better to get an allergy test, it can be life saving.

Staging can be determined by evaluation of the spread of the disease, either it is limited to the uterus, spread to the nearby structures or to distant organs. To determine the stages diagnostic tests are done, they can range from regular blood tests, colposcopy, ultrasonogram, CTscans, MRIs and biopsy or and intravenous urogram (IVU)

Simplified staging, is given below, there are more subtypes present in the FIGO classification
Early Stage

• Stage I - Tumors confined to the surface of the cervix disease

•  Stage II - Tumor grown beyond cervix and uterus, but not yet spread to the walls of the pelvis or lower part of vagina

• Later stage

•  Stage III - Tumour grown beyond the cervix to the pelvic side wall or the lower third of the vagina

•  Stage IV - Most advanced stage where the cancer has spread to nearby organs e.g. bladder or rectum, or more distant organs e.g. lungs, liver or bones

• In early cases, if the cancer is in stage I, a radical hysterectomy is done. (Hysterectomy is excision of the uterus along with one third of the vagina)

• Radiotherapy, or a combination of radiotherapy are given to shrink the cancer and can be followed by surgery. The oncologist along with a gynaecologist will decide on the treatment depending on stages, effectiveness of the therapies on the body. Patients who have excellent response to treatment will have better prognosis.

• Chemotherapy and targeted therapy also options that a doctor might choose from depending on the patient’s condition

Proper vaccination and screening test if followed thru it can reduce the risk of the disease along with the spread of it to the lymph node. Cervical cancer is the most preventable cancers, and has the best prognosis if diagnosed on time.

Q1. What is cervical cancer?
Cervical cancer is caused by a virus, Human papillomavirus. This virus causes abnormal growth of cells in the cervix, leading to cancer

Q2. How to prevent cervical cancer?
Proper vaccination against Human papillomavirus, and proper screening tests

Q3. When to give vaccination against cervical cancer?
Vaccination schedule: Vaccination can be done either in 2 or 3 dosage. It is to be administered to patients from an early age of 9 to 14 years, two dosages are fine, the difference between the two dosage should be about 5 months.15 years to 45 years a person needs to get 3 dosage, 0, 1-2, and 6 months.

Q4. Do men need this vaccine?
Yes, even though men do not have a cervix, it is to prevent the virus to cause warts and penile cancer.

Q5. I am 30 years old and my doctor asked me to get a Pap smear test, what is it? Why do I need it?
Pap smear test is a screening test, it is for Cervical Cancer. Usually done every 3 years.

Q6. I do not have any cancer patients in my family, is there a chance I might suffer from cervical cancer?
Yes, there is always a chance, so it's better to have the screening test done every 3 years

Q7. I had a hysterectomy, do I need to do a pap smear?
You should have one Pap smear done after your hysterectomy. If you did not have one you should check with your doctor.

Q8. I feel healthy, why should I go for the screening test?
Screening test is just a procedure to see you are healthy inside too. Sometimes the symptoms are silent, it's always better to be careful.

Q9. Will Pap smear hurt?
Usually it does not hurt, there might be a mild discomfort. If you feel unbearable pain, let your nurse know.

Q10. How will I know I have cervical cancer?
If you have the symptoms mentioned in our article about cervical cancer, consult with your gynaecologist, he/she will be able to do furthermore test and help your mind at ease.

Reference

1. Cervical Cancer. World Health Organization [Internet; cited 2019, October]. Retrieved from

2. Cervical cancer screening and management of cervical pre- cancer . Training of health staff in VIA and HPV detection test and cryotherapy [Internet; cited 2020, February]. Retrieved from

3. Mayo clinic- HPV vaccine, who needs it, how it. Mayo Clinic [Internet; cited 2019, October]. Retrieved from

4. Cancer information, Cervical Cancer. National University Cancer Institute Singapore [Internet; cited 2019, October]. Retrieved from

5. HPV Vaccination Comprehensive Cervical Cancer Control . World Health Organization. A guide to essential practice [Internet; cited 2019, October]. Retrieved from https://www.who.int/immunization/hpv/plan/hpv_vaccine_intro_guide_c4gep_who_2013.pdf/en/

6. Staging. Cervical cancer A guide for journalists on cervical cancer and its treatment [Internet; cited 2019, October]. Retrieved from https://www.roche.com/dam/jcr:f23e932c-df84-4ce0-9223-b508eaf4232c/%20Cervical%20Cancer%20Concise%20Guide%20%20September%202016_Pharma.pdf /en/

7. Health Hub. Cervical Cancer Screening [Internet; cited 2019, October]. Retrieved from https://www.healthhub.sg/a-z/diseases-and-conditions/703/faqs-on-screening-for-cervical-cancer-pap-smear#1/en/

8. Cancer Treatment Centers of America. Top questions about cervical Cancer [Internet; cited 2019, October]. Retrieved from