Catcinoma Cervix / Cervix Cancer
The cervix is the smooth organ that forms the entrance to a woman’s uterus. Cancer of the cervix has no symptoms. That’s why the only way to detect it is through a Pap smear, a standard life-saving screen that is performed as part of a woman’s yearly pelvic examination.
Every year, nearly 600,000 American women are diagnosed with cervical dysplasia; 9,710 women are diagnosed with cases of invasive cervical cancer. Early detection of abnormal changes can save lives. Unfortunately, of those women who die of cervical cancer today, 80 percent have not had a Pap smear in five years or more. Cervical cancer, even though falling 2 percent per year, is still the second most common cause of cancer deaths in women. Ironically, it is one of the most preventable and curable by “early identification” of cervical intra-epithelial neoplasia (CIN) and micro-invasive disease.
A Pap test or Pap smear, named after the doctor (George Papanicolaou) responsible for initiating the procedure, is the main way doctors check to see if a woman has developed abnormal cells on the coating (the very top layer of cells) of her cervix. The test is quick, simple, and painless, and shows the presence of an infection, inflammation, abnormal cells, or cancer. The doctor collects a sample and the lab pathologist (cytology lab) analyzes the “smear” under a microscope.
The Pap test may reveal abnormal cell growth, or dysplasia (precancerous cell changes), in the area of the cervix. Abnormal cells look different microscopically from normal cells in that their nuclei show certain specific changes, and that they divide more quickly than normal cells.
A Pap test is done during an internal pelvic examination. During a Pap test, the doctor uses a tiny wooden spoon to painlessly scrape some cells from the surface of the cervix and smear these cells onto a small glass slide, which will be stained with a special dye that identifies abnormal cells.
For accurate results, a Pap smear should be done when a woman is not menstruating. Additionally, she should avoid douching, using vaginal medicines, spermicidal birth control foams, and other creams or jellies because these substances may wash away or hide abnormal cells. If that should happen, her doctor might mistakenly believe that the woman’s Pap test is normal.
Current guidelines from the National Cancer Institute recommend that all women who are or have been sexually active, or are 18 years of age or older, should have regular Pap tests and pelvic exams.
- A Pap test can catch early signs of cancer before the disease spreads deeper into the cervix and before the cancer spreads to other parts of the body.
- About 50 million Pap tests are performed every year in the United States, with up to 7 percent of the women tested having some type of abnormal results.
- Between 60 percent and 80 percent of American women who are diagnosed with invasive cancer (cancer that spreads) each year, did not have a Pap smear in the earlier year, according to doctors at the Memorial Sloan-Kettering Cancer Center in New York City.
Research published in the British Journal of Obstetrics and Gynecology reveals that DNA from the human papilloma virus (HPV) is present in almost all invasive cervical cancers. Therefore, having a yearly Pap test, which screens for HPV, is crucial in detecting cervical cancer. Researchers have also discovered “compelling evidence” that persistent HPV infection is the “pivotal step” in the development of cervical cancer. In addition, there are high-risk types of HPVs: numbers 16 and 18 are “definite” carcinogens in humans and HPV 16 is the most common high-risk type. In fact, there are studies that show a greater odds ratio for “the association between HPV and cervical carcinoma than for smoking and lung cancer.”
When a Pap test uncovers abnormalities, a diagnosis of cervical dysplasia is made, and the dysplasia is classified according to a system. Cervical dysplasia, also called cervical intraepithelial neoplasia (CIN), is rated as mild, moderate, or severe. Cervical dysplasia sometimes, but not always, evolves into cervical cancer. A Pap test can catch early signs of cancer before the disease spreads deeper into the cervix and before the cancer spreads to other parts of the body.
Abnormal cells are classified as atypical squamous cells of undetermined significance (ASCUS). Other abnormal cells that are mild but more definite are called low-grade squamous intraepithelial lesions (LSIL). How to handle these mild abnormalities is controversial; some physicians take a “wait-and-see” attitude. That’s because often the cell abnormalities clear up without treatment. So a more conservative physician recommends follow-up Pap tests at three or six months. Others suggest a more aggressive approach: colposcopy, a procedure that allows a physician to use a special microscope to provide closer examination of the cervix, and/or biopsy.
During the procedure the doctor may take tissue samples (a cervical biopsy) from the area. If still more tissue is needed, the patient undergoes a cold cone biopsy. The patient is put in the hospital under general anesthesia and a large tissue sample is taken. The cone biopsy often removes all the cancerous tissue. The reason for all these tests is to accurately match a patient’s medical condition with the most effective therapies available.
Signs and symptoms of cervical cancer usually don’t appear until precancerous cervical cells become cancerous and invade nearby tissue. Because precancerous changes in the cervix do not cause pain or abnormal bleeding, there are usually no signs that would make a woman suspect that she had precancerous cells in her reproductive organs.
The most common symptom of cervical cancer is abnormal bleeding. This could include:
- Any spotting or bleeding that occurs between normal periods, after sexual intercourse, douching, or during an internal pelvic examination
- Menstrual bleeding that lasts longer and is heavier than usual
- Increased vaginal discharges
- Painful intercourse
- Bleeding after menopause
Fortunately, cervical cancer is a slow-growing disease. Therefore, a yearly Pap smear will flag any abnormal changes in the cervix that need to be checked out to determine their exact cause, amount, behavior, and type. A physician will decide whether other risk factors warrant further testing. African-American, Hispanic, Native-American women, and women over age 65 are at increased risk because of their general lack of access to good medical care.
Other risk factors for cervical cancer and dysplasia are:
- Starting sexual intercourse at an early age (16 or younger)
- Having multiple sexual partners
- Smoking cigarettes or passive smoking
- Having a history of gynecological cancer
- Using oral contraceptives for five years or more
- Having a diet that is low in vitamin A
- Having a history of sexually transmitted disease, especially HPV infection
- Having the HIV (human immunodeficiency infection), which causes AIDS
- Having been exposed to the drug known as DES (diethylstilbestrol), which had been used by the medical community between 1938 and 1971 to prevent miscarriages
In the journal Nature, some startling statistics in a Swedish study revealed that sometimes, there is a genetic link between women who had cervical cancer and their biological relatives. Over 126,000 relatives of over 71,000 cases of women with cervical cancer helped determine the conclusion of that study.
Cancer “staging” means determining the amount of a cancer a person has, especially when the disease has spread from one spot to another. It is very important to know the exact “grade” or amount of cancer a patient has developed, to plan the best treatment for her. Tissue removed during a cervical biopsy will be staged as follows:
- Stage I: Cancer has not spread to nearby locations in the body.
- Stage II: A small amount of cancer (only visible using a microscope) has spread. The cancer has extended beyond the cervix but not to the pelvic sidewall or the vagina.
- Stage III: A large amount of cancer is deep in the cervix. The cancer extends to the pelvic sidewall, involves the lower third of the vagina or obstructs one or both ureters.
- Stage IV: The cancer spreads to distant organs beyond the pelvis or involves the pelvis or involves the bladder or rectum.
- Stage IVA: The five-year survival rate is between 20 percent to 30 percent
- Stage IVB: It is unusual to survive five years.
The survival rate (living for five years or more after treatment) for women with stage I cancer is good: 80 percent to 85 percent. For women with stage IV cervical cancer, survival is less than 12 percent.
Cancer of the cervix is treated differently from other types of cancer in the body, and it may be treated differently from other types of cancer found in the female reproductive tract, such as the ovaries and uterus. Every cancer treatment will depend on the size, amount, and type of cancer a patient has developed. The most common cervical cancer treatments may include:
- Some type of surgery.
- Radiation therapy.
- A combination of surgery and radiation.
- Chemotherapy for advanced stage disease.
- Laser surgery (a thin beam of light aimed at the abnormal cells) may be used to destroy abnormal cells, as well as those cells that have already turned into cervical precancer cells.
- Surgery (cutting out abnormal cells) is used to remove cancerous cells that have already spread outside the cervix.
- Hysterectomy (removal of the uterus, or the uterus and cervix) is used to treat patients whose cancer has spread from the cervix to other reproductive organs.
- Combined radiation therapy and chemotherapy (cisplatin) is a powerful treatment that is used for patients whose cervical cancer has spread to other reproductive organs, and possibly to other places in the body.
- Chemotherapy (5-FU with platinum) can enhance the value of radiotherapy for specific indications.
Yearly pelvic examinations to identify and treat precancerous conditions remain the most effective ways to prevent cervical cancer. A woman should think preventively by avoiding partners with high-risk sexual histories and insisting on the use of a condom.
The good news is that scientists have developed a vaccine that can potentially prevent cancer of the cervix associated with HPV 16 and 18. The FDA recently approved this vaccine in June 2006 for use in young women ages 9 to 26.