Cervix is the lower most part of the uterus and projects into the vaginal cavity. GLOBOCAN 2020 estimates 604000 new cases of cervical cancer with 242000 deaths annually worldwide with the majority (85% and 90% respectively) occurring in low and middle income countries. Regional differences in cervical cancer burden are mainly due to lack of access to vaccination, screening and treatment.
Cervical cancer is the most common cancer of the female reproductive tract in India. 95% of cervical cancer cases happen due to persistent long term infection with human papilloma virus (HPV), a sexually transmitted virus and this infection is the necessary cause of cervical cancer. Most sexually active women get infected with HPV at some point during their lifetime.
In most cases, the infection clears out on its own by the immune system but in ~ 10% of women, the infection persists. Persistent HPV infection, if left untreated, causes cervical cancer. It takes on an average 15-20 years for abnormal cells to progress through precancerous stages to cervical cancer.
Watch out for these symptoms: Women should consult her doctor and get examined if they notice: unusual bleeding between periods or after menopause or after sexual intercourse; excessive foul smelling vaginal discharge; unexplained pain in the back, legs or pelvic region, vaginal discomfort, loss of weight, fatigue, loss of appetite, swelling in the legs. Lifestyle factors like unsafe sex practices (having more than one partner), presence of other sexually transmitted infections including HPV, smoking, young age at first pregnancy, increasing number of births, oral contraceptive pill usage, low immunity and poor vaginal hygiene increase the risk of developing cervical cancer. With regular screening it is possible to detect early abnormalities in a non-invasive precancerous stage before it develops into an invasive cancer.
What must be done? – Preventive strategies Vaccinating girls at age 9-14 years with HPV vaccine (before sexually active) with two doses is highly effective way to prevent HPV infection, cervical cancer and other HPV-related cancers. Three doses of HPV vaccine are recommended for teens and young adults who start vaccination at ages 15 through 26 years and for immunocompromised persons. Vaccination is not recommended for everyone older than age 26 years.
All sexually active women should get themselves screened to detect the precancerous lesions. The ability to easily visualize and sample the cervix contributed to ease of screening in cervical cancer. Screening tests includes cervical cytology (Pap smear test), VIA (Visual inspection with acetic acid) or HPV testing.
Screening should begin at the age of 30 and should be done every 5 years till the age of 65. Women, who have received abnormal results for screening, should get themselves assessed every 6 months to one year as per their doctor’s advice. Avoiding smoking, using barrier contraceptives and voluntary male circumcision are other important ways to prevent HPV infection.
Treatment modalities Pre-invasive cancerous lesions can be easily treated by using heat (thermal ablation) or freezing (cryotherapy) or burning (laser ablation) or Loop Electrosurgical Excision Procedure (LEEP) or cone biopsy as per availability. If women develop invasive cervical cancer, doctors do physical examination and diagnostic tests to find out cancer’s stage. Cervical biopsy is needed during which a small sample of tissue from the cervix is taken to prove cancer.
Imaging with the help of CT or MRI scan helps to determine the size, extent and spread of the cancer to guide further treatment. Based on these findings, “clinical stage of the cancer” describing the extent of the cancer spread in the body is determined. The FIGO (International Federation of Gynecology and Obstetrics) staging system is used to stage cervical cancer.
Cervical cancer stage ranges from stages I through IV. The lower number means less spread of cancer. A higher number, such as stage IV, means a more advanced cancer.
For simplicity: Stage I- Cancer cells have grown from the surface of the cervix into deeper tissues of cervix only; Stage II – Cancer has spread beyond the cervix and uterus into the upper part of the vagina or into the parametrium (tissues on the both sides of the uterus); Stage III – Cancer has spread into the lower part of the vagina or the walls of the pelvis and block the ureters (tubes which carry urine from kidneys to bladder) or the lymph nodes; Stage IV – Cancer has grown into the urinary bladder or rectum or far away organs like lungs or bones. The treatment options available for cervical cancer include surgery, radiation therapy and systemic therapy. The modality of treatment is determined by different factors, like age and condition of the patient, type and stage of cancer etc.
In early stages when there is no spread to parametrium or beyond, either surgery (radical hysterectomy) or radiotherapy offers similar cure rates. In advanced stages, often combined treatment of radiotherapy and chemotherapy (chemoradiation) or sometimes chemotherapy alone is required to adequately control the disease in a hope to achieve cure. So the message which we have to understand is, if caught in pre-cancerous to early stages, the cervical cancer can be treated easily and a life can be saved.
Most importantly, cervical cancer is one of the few cancers which can be prevented and detectable in early stage by proper screening. So “Yaad Rakehin aur Screen Karein”. References: International Federation of Gynecology and Obstetrics (FIGO), World health organization (WHO), American cancer society.
