Cervical Cancer

Cervical cancer is a disease where cancer cells form in tissues of the cervix, and begin to grow uncontrollably. These cells can form tumors and spread to other parts of the body.

Cervical cancer develops in the thin layer of cells called the epithelium, which cover the cervix. Cells found in the this tissue have different shapes:

• Squamous cells (flat and scaly). Most cervical cancer arises from changes in the squamous cells of the epithelium (squamous cell carcinoma).
• Columnar cells (column-like). These cells line the cervical glands and cancers here are known as adenocarcinomas.
• In rare cases, cancer can occur in cells that form the supportive tissue around the cervix (the stroma).

Cervical cancer usually begins slowly with precancerous abnormalities, and even if cancer develops, it generally progresses very gradually. Cervical cancer is the most preventable type of cancer and is very treatable in its early stages. Regular Pap tests and human papilloma virus (HPV) screening can help detect this disease early.

Benjamin
Cliff
Si rui
Yuan Yi

• Human papillomavirus (HPV)
• Sexual History

Human Papilloma Virus (HPV)
Human papillomavirus (HPV) is a virus that can infect:

• The genital tract
• The external genitals
• The area around the anus
  

HPV has nothing to do with HIV, the virus that causes AIDS. There are 46 genetic types of HPV, but not all are dangerous. Only certain types of HPV, which can be transmitted from one person to another during sexual contact, increase the risk of cell dysplasia (abnormal cell growth) and/or progression to cervical cancer.

The HPV types that produce genital warts (lesions that are raised and bumpy, or flat and almost impossible to see) are different from those that cause cervical cancer. However, women who have a history of genital warts have almost twice the risk of an abnormal Pap smear as other women.

Nice To Know:
Hybrid Capture Test
This new test, approved by the FDA in 1999, is able to detect 14 types of human papillomavirus (HPV) that can infect the cervix. It uses chemoluminescence (transfer of chemical energy into light) techniques to accurately determine the presence or absence of HPV viruses of low risk or medium-high risk for cervical cancer.

Sexual History

A woman has a higher-than-average risk of developing cervical if she:

• Has had multiple sexual partners
• Began having sexual relations before the age of 18
• Has a partner who has had sexual contact with a woman with cervical cancer

Other Risk Factors

It is probable that other factors contribute to cervical cancer, such as:

• Poverty. Women who are poor may not have access to medical services that detect and treat precancerous cervical conditions. When such women develop cervical cancer, the disease usually remains undiagnosed and untreated until it has spread to other parts of the body. Women who are poor are often undernourished, and poor nutrition can also increase cervical cancer risk.
• Pap test history. Not having regular Pap tests increases the chance of unrecognized cervical cancer. Between 60% and 80% of women with newly diagnosed cervical cancer have not had a Pap test in at least five years.
• Tobacco use. Women who smoke are about twice as likely to develop cervical cancer as women who do not. The more a woman smokes - and the longer she has been smoking - the greater the risk.
• Eating habits. A diet that doesn't include ample amounts of fruits and vegetables can increase a woman's risk of developing cervical cancer.
• Weakened immune system. A woman whose immune system is weakened has a higher-than-average risk of developing cervical lesions that can become cancerous. This includes women who are HIV-positive (infected with the virus that causes AIDS). It also includes women who have received organ transplants and must take drugs to suppress the immune system so that the body won't reject the new organ.

• Hormonal medications. Some experts suggest that hormones in oral contraceptives (birth control pills) can make women more susceptible to Human papillomavirus (HPV). At least one study has indicated that taking birth control pills significantly increases a woman's risk of developing HPV-related genital warts. Other research suggests that using oral contraceptives for five years or longer slightly elevates a woman's risk of developing cervical cancer, especially if she began taking the Pill before the age of 25.
• Diethylstilberstrol (DES). A rare type of cervical cancer has been diagnosed in a small number of women whose mothers took diethylstilbestrol (DES), a medicine that was once used to prevent miscarriage.
• Douching. Because douching may destroy natural antiviral agents normally present in the vagina, women who douche every week are more apt to develop cervical cancer than women who do not.
• Chemical exposure. Women who work on farms or in the manufacturing industry may be exposed to chemicals that can increase their risk of cervical cancer.

Cervical cancer is the second most common cancer in women worldwide and the fifth most common type cancer among women in Singapore (cervical cancer has a 50 percent fatality rate – approximately 200 women are diagnosed with cervical cancer in Singapore each year, out of which an estimated 100 will die.) It is a leading cause of cancer-related death in women in underdeveloped countries. Approximately 500,000 cases of cervical cancer are diagnosed worldwide each year.

Fact: 13.9 women per 100,000 population with cervical cancer in Singapore 1993-97 (Surveillance and Risk Assessment Division, CCDP, Health Canada)


Resource/Link: http://www.cureresearch.com/c/cervical_cancer/prevalence.htm

Cervical cancer is asymptomatic; it can exist for years undiagnosed and may only be found upon medical testing.

-Abnormal bleeding.Women with cervical cancer may experience abnormal virginal bleeding. This can be heavy or light bleeding during the month.

-Unusual heavy discharge. An increased vaginal discharge is also a symptom of cervical cancer. It may be foul smelling, watery, thick, or contain mucus. It varies from woman to woman. It is important to report any unusual vaginal discharge to your doctor.

-Pelvic pain. Pelvic pain that is not related to the normal menstrual cycle can be a cervical cancer symptom. Many women describe them ranging from a dull ache to sharp pains that can last hours. It can be mild or severe.

-Pain during urination. Bladder pain or pain during urination can be a symptom of advanced cervical cancer. This cervical cancer symptom usually occurs when cancer has spread to the bladder.

-Bleeding between regular menstrual periods, after sexual intercourse, douching, or pelvic exam. Bleeding after sexual intercourse, douching, or pelvic exam can be cervical cancer symptoms.

Symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or faeces from the vagina, and bone fractures.

There are a few methods in diagnosis cervical cancer;

-The Pap Smear

The Pap smear plays a vital role in diagnosing cervical cancer. It is how most women discover they suffer from cervical cancer. The Pap smear is a simple test that can reveal cervical abnormalities long before they progress into cancer. All women should have a regular Pap smear, unless their physician has advised them they no longer need one. This may also include post-menopausal women and those who have had hysterectomies.

-Colposcopy Exam

If Pap smear results reveal cervical abnormalities, a colposcopy is then scheduled. A colposcopy is an in-office exam that allows the doctor to view the cervix more closely with a colposcope. A colposcope is a lighted instrument that magnifies the cervix. It rests externally, outside of the vagina, during the exam. The images seen from the colposcope may be projected on a computer or television screen. You are not obligated to watch, but it may help you understand the exam better.

-Cervical Biopsy and Endocervical Curettage

During the colposcopy, the doctor may perform a cervical biopsy depending on what is found during the exam. A cervical biopsy involves removing small amount of cervical tissue to be examined under a microscope. It takes only seconds for the doctor to gain a tissue sample and is only momentarily uncomfortable. Depending on the findings during the colposcopy, a few areas of the cervix may be biopsied. Along with a cervical biopsy, an endocervical curettage (ECC) may also be done. During an ECC, the doctor uses a small brush to remove tissue from the endocervical canal, the narrow area between the uterus and cervix. An ECC can be moderately painful, but the pain disappears when the ECC is done. Biopsy and ECC results usually take less than two weeks to return. Your doctor may have you schedule another visit to go over the results with you or he/she may call you by phone to inform you of the results.

-Cone Biopsy and LEEP

There are times when a larger biopsy needs to be done to diagnose cervical cancer. In these cases, a cone biopsy may be performed. During a cone biopsy, a cone shaped piece of tissue is removed under general anesthesia. A cone biopsy is also used to remove pre-cancerous tissue from the cervix. A loop electro surgical excision procedure (LEEP) is a procedure done under local anesthesia to remove tissue from the cervix. A LEEP uses an electrically charged wire loop to remove a tissue sample. This method is more commonly used to treat high grade cervical dysplasia, rather than diagnose cervical cancer.

-The Results are In

Once the biopsy results return, cervical cancer can either be ruled out or diagnosed. If a cervical cancer diagnosis is made, the next step is to determine what stage the cervical cancer is in. There are five cervical cancer stages and each represents how far advanced the cancer has spread. Once the stage of cervical cancer has been determined, a treatment plan can then be developed.

If the biopsy shows that you have cancer, your doctor will do a thorough pelvic exam and may remove additional tissue to learn the extent (Stage) of your disease. The stage tells whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body.

To learn the extent of disease and suggest a course of treatment, the doctor may order some of the following tests:

• Chest x-rays: X-rays often can show whether cancer has spread to the lungs.

• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your organs. You may receive contrast material by injection in your arm or hand, by mouth, or by enema. (Some people are allergic to contrast materials that contain iodine. Tell your doctor or nurse if you have allergies.) The contrast material makes abnormal areas easier to see. A tumor in the liver, lungs, or elsewhere in the body can show up on the CT scan.

• MRI: A powerful magnet linked to a computer is used to make detailed pictures of your pelvis and abdomen. The doctor can view these pictures on a monitor and can print them on film. An MRI can show whether cancer has spread. Sometimes contrast material makes abnormal areas show up more clearly on the picture.

• Ultrasound: An ultrasound device is held against the abdomen or inserted into the vagina. The device sends out sound waves that people cannot hear. The waves bounce off the cervix and nearby tissues, and a computer uses the echoes to create a picture. Tumors may produce echoes that are different from the echoes made by healthy tissues. The picture can show whether cancer has spread.

Treatment

Many women with cervical cancer want to take an active part in making decisions about their medical care. It is natural to want to learn all you can about your disease and your treatment choices. However, shock and stress after the diagnosis can make it hard to think of everything you want to ask the doctor. It often helps to make a list of questions before an appointment.

To help remember what the doctor says, you may take notes or ask whether you may use a tape recorder. You may also want to have a family member or friend with you when you talk to the doctor—to take part in the discussion, to take notes, or just to listen.

You do not need to ask all your questions at once. You will have other chances to ask your doctor to explain things that are not clear and to ask for more information.

Your doctor may refer you to a specialist, or you may ask for a referral. Gynecologists, gynecologic oncologists, medical oncologists, and radiation oncologists are specialists who treat cervical cancer.

Getting a second opinion

Before starting treatment, you might want a second opinion about the diagnosis and treatment plan. Many insurance companies cover a second opinion if you or your doctor requests it. It may take some time and effort to gather medical records and arrange to see another doctor. Usually it is not a problem to take several weeks to get a second opinion. In most cases, the delay in starting treatment will not make treatment less effective. To make sure, you should discuss this delay with your doctor. Some women with cervical cancer need treatment right away.

Preparing for treatment

The choice of treatment depends mainly on the size of the tumor and whether the cancer has spread. If a woman is of childbearing age, the treatment choice may also depend on whether she wants to become pregnant someday.

Methods of treatment

Your doctor can describe your treatment choices and the expected results of each. You and your doctor can work together to develop a treatment plan that meets your medical needs and personal values.

Women with cervical cancer may be treated with surgery, radiation therapy, chemotherapy, radiation therapy and chemotherapy, or a combination of all three methods.

Surgery

Surgery treats the cancer in the cervix and the area close to the tumor.
Most women with early cervical cancer have surgery to remove the cervix and uterus (total hysterectomy). However, for very early (Stage 0) cervical cancer, a hysterectomy may not be needed. Other ways to remove the cancerous tissue include conization, cryosurgery, laser surgery, or LEEP.

Some women need a radical hysterectomy. A radical hysterectomy is surgery to remove the uterus, cervix, and part of the vagina.

With either total or radical hysterectomy, the surgeon may remove both fallopian tubes and ovaries. (This procedure is a salpingo-oophorectomy.)

The surgeon may also remove the lymph nodes near the tumor to see if they contain cancer. If cancer cells have reached the lymph nodes, it means the disease may have spread to other parts of the body.

Radiation therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area.

Women have radiation therapy alone, with chemotherapy, or with chemotherapy and surgery. The doctor may suggest radiation therapy instead of surgery for the small number of women who cannot have surgery for medical reasons. Most women with cancer that extends beyond the cervix have radiation therapy and chemotherapy. For cancer that has spread to distant organs, radiation therapy alone may be used.

Doctors use two types of radiation therapy to treat cervical cancer. Some women receive both types:

• External radiation: The radiation comes from a large machine outside the body. The woman usually has treatment as an outpatient in a hospital or clinic. She receives external radiation 5 days a week for several weeks.
  
• Internal radiation (intracavitary radiation): Thin tubes (also called implants) containing a radioactive substance are left in the vagina for a few hours or up to 3 days. The woman may stay in the hospital during that time. To protect others from the radiation, the woman may not be able to have visitors or may have visitors for only a short period of time while the tubes are in place. Once the tubes are removed, no radioactivity is left in her body. Internal radiation may be repeated two or more times over several weeks.

Chemotherapy

Chemotherapy uses anticancer drugs to kill cancer cells. It is called systemic therapy because the drugs enter the bloodstream and can affect cells all over the body. For treatment of cervical cancer, chemotherapy is generally combined with radiation therapy. For cancer that has spread to distant organs, chemotherapy alone may be used.

Anticancer drugs for cervical cancer are usually given through a vein. Women usually receive treatment in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, a woman needs to stay in the hospital during treatment.

-Early Detection:

One of the most important prognostic factors involves how early the cancer is detected and how far it has spread. Women who undergo annual pelvic exams and Pap smears have a greater chance of detecting any abnormalities or cancerous tissue during the early stages. This can play a crucial role regarding the chances of treating the cancer successfully or having the disease come back. Many procedures such as radiotherapy, cryotherapy, laser treatment or chemotherapy may be effective in removing all the cancerous tissue if the cancer is detected early enough and is restricted to the cervix area. Unfortunately, a patient’s chance of survival decreases if the cervical cancer has not been detected early enough and spreads to other parts of the body.

-Stages Of Cervical Cancer:

Stage 1A- Cancer is confined to the cervix area. The cancer is not deeper than 5 millimetres and not wider than 7 millimetres.

Stage 1B- Cancer is still within the cervix and either: can only be seen with a microscope and is deeper than 5 millimetres or wider than 7 millimetres; or can be seen without a microscope and may be larger than 4 centimetres.

Stage 2- cancer has spread beyond the cervix to the upper two thirds of the vagina but not to tissues around the uterus at first. However, the cancer will spread to the tissue around the uterus eventually later on.

Stage 3A- cancer has spread to the lower third of the vagina but not to the pelvic wall.

Stage3B- cancer has spread to the pelvic wall and/or the tumor has become large enough to block the ureters. This may lead to the enlargement or dysfunction of kidneys due to e blockage. Cancer cells may also have spread to lymph nodes in the pelvis.

Stage 4A- cancer has spread to the bladder or rectal wall and may have spread to lymph nodes in the pelvis.

Stage4B-cancer has spread beyond the pelvis and pelvic lymph nodes to other places in the body, such as the abdomen, liver, intestinal tract, or lungs.

Recurrent cancer: The cancer was treated, but has returned after a period of time during which it could not be detected. The cancer may show up again in the cervix or in other parts of the body.


-Size Of The Tumour:

Tumours are abnormal masses of tissue which can be either normal benign growths or malignant cancerous ones. The size of the cancerous cells or tumour is another prognostic factor for cervical cancer patients. Because cancer cells can divide very rapidly, it’s crucial to detect the disease while the tumours are still relatively small. In fact, a tumour starts from a single cell so smaller masses of cancerous cells are less likely to spread. In most cases, doctors are able to successfully treat small detected tumours.

-Types Of Cervical Cancer:

Prognostic factors are also determined by the type of cervical cancer you contract. Approximately 75% of patients are diagnosed with squamous cell cervical cancer and approximately 10% of patients have adenocarcinoma cervical cancer. A much smaller number of patients develop a form of cancer containing elements of both types. Less than 1% of the population will develop another very rare form of this disease. Certain types of cervical cancer don’t respond as well to treatment.

Examples of cervical cancers:

Squamous cell (epidermoid)- comes from the outer portion of the cervix which protrudes into the vagina. Approximately 80-90% of cervical cancers are squamous cell carcinomas

Adenocarcinoma- comes from cells that make up glands in the cervix. It starts on the more "inner" portion of the cervix, from the same type of cells lining the uterus. Approximately 10% of cervical cancers are adenocarcinoma.

Lymphoma- Primary cervical lymphoma is rare with less than 60 cases reported as of 2005. The extent of disease, size of primary tumour, and type of lymphoma are significant prognostic features.


Resource/links: http://www.thehealthresource.com/cancer_info/cervical_cancer3.cfm