Cervical cancer is the third most common cancer in women, following breast and bowel cancers. Cervical Cancer refers malignant tumor of cervix, the lowest part of the uterus (one of female genital organs), due to abnormal proliferation and growth.
However, it is possible to minimize prevalence of cervical cancer and rate of death (mortality) secondary to this cancer by using screening tests commonly.
Risk Factors, Symptoms and Occurrence
Risk factors of the cervical cancer are as follows:
- HPV infection (HPV DNA is positive in 95% of cervical cancer cases). HPV virus is sexually transmitted to the cervix.
- First sexual intercourse at an early age (before 16)
- Many sexual partners (the same applies to both men and women)
- Smoking (active or passive)
- Diet (risk of the cervical cancer increases if the diet is poor in fruits and vegetables)
- Low socioeconomic level
- Oral contraceptives (especially long-term (longer than 5 years) use)
The most common symptom of the cervical cancer is vaginal bleeding at irregular intervals that are not related to periods. Although the bleeding can sometimes be heavy, it is usually in the form of “spotting”. It can be more evident after a sexual intercourse. Vaginal discharge with foul odor or blood in urine or stool can be seen in advanced stages of the disease.
Intact cervix starts manifesting changes related to infection 3 to 8 months of inoculation period after the cervix is exposed to HPV.
- Such changes may spontaneously disappear or convert into low-grade cervical lesion.
- Low-grade cervical lesions regress and disappear in 60% of patients in 2 to 3 years, but 15% of cases can progress into high-grade cervical lesion in 3 to 4 years based on combined effects of other carcinogens.
- Thirty to seventy percent of patients with high-grade cervical lesion can develop cancer in 10 years, if left untreated.
Stages of the Cervical Cancer
- Stage I: Cancer is still confined to the cervix.
- IA; cancer cells can be seen only in biopsy specimens under microscope and are confined to the cervix.
- IB; cancer cells can be seen with naked eye during examination.
- IB1; Cancer is smaller than 4 cm.
- IB2: Cancer is larger than 4 cm.
- Stage II: The cancer spread to soft tissue nearby the cervix or vaginal dome (the upper part of the vagina).
- Stage III: The cancer spread to extra-cervical tissues, including lateral walls of pelvis and the lower part of the vagina. It may result in swelling in feet and/or problems in urine flow.
- Stage IV: The cancer involves urinary bladder and rectum or distant organs, such as liver and lung, by spreading out of the cervix or any anatomic region mentioned above.
Diagnosis of the Cervical Cancer
In the Pap test, a vaginal brush specimen is collected and normal and abnormal cells in the specimen are classified by pathologists. For suspected cases, colposcopy is indicated. If positive finding is revealed out by the colposcopic examination – optical magnification to visualize and inspect the cervix-, a biopsy specimen is collected during the colposcopy.
If abnormality is confined to superficial cells, as evidence by pathological examination of the biopsy specimen, cervix should be excised with conization. Conization (cone biopsy) is a diagnostic method, but it can be also sufficient for treatment.
If biopsy shows cervical cancer, it is necessary to determine spread of the disease for making evidence-based treatment decision. Size and spread of tumor and its relation with the urinary bladder on the anterior contour and with the bowel on the posterior contour can be clarified with vaginal and rectal exam, MRI and PET/CT. Ultrasound cannot clearly image status of the cervical cancer
Treatment Methods of the Cervical Cancer
Cervical cancer usually prefers regional spread. Lymphatic metastasis is more likely. Hematogenous dissemination (spread through blood circulation) is somewhat infrequent.
Surgery is usually preferred for cases that are confined to the uterus. The extent of the surgery is determined according to age of the patient, future conception plans, size of tumor and the extent of spread. There are many surgical techniques with varying extent depending on needs, including but not limited to conization of the cervix (uterus is left untouched) and large excision of parametrial tissues and the upper one third part of the vagina along with pelvic and para-aortic lymph node dissection.
If the cancer moves beyond the uterus and spreads to parametrial tissues, radiotherapy is the first-line treatment rather than surgery. Chemo-radiotherapy can be considered as first-line treatment option when volume of the cervical tumor enlarges.
For the patients with tumor-positive surgical margin or cancerous cells in lymph nodes as evidenced by postoperative pathological examination, chemo-radiotherapy is required.