What is Cervical Cancer?
Cervical cancer is one of the top cancers that affect women worldwide, coming in as the fourth most common and 14th in all cancers. The key ways to struggle against cervical cancer are early prevention and screening. These methods are the most effective for reducing both the spread of cervical cancer and death rates from it.
In developed places like the United States, the main focus is to detect early any high-risk HPV lesions. This is done through HPV testing and Pap smears. Even though HPV testing is not advised for women under 30 years old, those at low-risk should start having Pap tests from age 21, up to age 65. This is as per recommendations made by the United States Preventive Services Task Force. The newer advice is to have these tests every 3 to 5 years, depending on previous test results and the use of both Pap and HPV tests.
However, there can often be inequalities in accessing these screenings, early detection rates, and getting prompt treatment. Screening rates tend to be lower in areas where people have low incomes or fewer resources, and can vary according to race, ethnicity, and age. Studies showed that women with obesity and chronic disease may not be screened as frequently for cervical and breast cancer. Some barriers include lack of knowledge, fear, embarrassment and low perceived risk, as a study among ethnic minority women in the UK found. Haitian women, another study found, faced barriers in language and understanding health issues, along with socioeconomic hurdles. In the US, more black women die from cervical cancer than other populations.
Cervical cancer is actually a sexually transmitted infection (STI), which means it can be prevented. Education, screening, and intervention can reduce cervical cancer rates worldwide. There’s been a vaccine for preventing cervical cancer since 2006. This can help reduce cancer death rates, especially in populations with higher mortality rates and in developing countries where regular screenings may not be possible.
What Causes Cervical Cancer?
Research shows that the human papillomavirus, or HPV, is encountered by most sexually active people at some point in their lives. There are more than 130 known types of HPV, and 20 of these are linked to cancer. Data on exposure to HPV is only available for women since men are not typically screened for it, unless participating in research studies.
Two types of HPV, types 16 and 18, are most frequently identified in cases of invasive cervical cancer. According to population-based studies, people under the age of 25 are most likely to carry high-risk HPV. However, deaths from cervical cancer are most common in middle-aged women, between 40 and 50 years. Research further shows that HPV-related cervical disease in women under 25 usually goes away on its own. Yet, if multiple types of HPV are present, the chances of the diseases clearing up on their own decreases, potentially leading to cancer.
HPV can be transmitted through any skin-to-skin contact, such as sexual activity, hand-to-genital contact, and oral sex. Factors that increase the risk of contracting HPV and developing cervical cancer include starting sexual activity at a young age, having multiple sexual partners, giving birth to many children, smoking, having herpes simplex, HIV, other genital infections, and using oral contraceptives.
Risk Factors and Frequency for Cervical Cancer
Persistent HPV infection is responsible for more than 99% of all cervical cancers. A significant number of new cases and deaths related to cervical cancer occur globally each year. Most of these cases are found in developing countries. In the United States specifically, around 4,000 women die yearly from this disease, with black, Hispanic, and women in low-resource areas being the most affected. Mortality rates are highest among women who have not been screened in the past five years or have not consistently followed up after identifying a precancerous cervical lesion. These high-risk women also appear to be less likely to receive the HPV vaccination.
- More than 99% of all cervical cancers are caused by persistent HPV infection.
- Each year, over 500,000 new cases of cervical cancer and approximately 250,000 deaths occur worldwide.
- Eighty percent of these cases are in developing countries.
- In the United States, about 4,000 women die from cervical cancer every year.
- Black, Hispanic, and women in low-resource areas are most affected and have a higher mortality rate.
- Women who haven’t been screened in the last five years or don’t consistently follow-up after identifying a precancerous lesion have a higher risk of mortality.
- Women with the highest risk are often less likely to get the HPV vaccination.
Signs and Symptoms of Cervical Cancer
Early stages of cervical cancer often don’t present clear symptoms. It’s important for women to share their complete medical history with their doctor, including their sexual history, such as age at first sexual intercourse, any after-intercourse bleeding or discomfort, and past sexually transmitted infections (STIs) such as HPV and HIV. The doctor will also want to know about the number of lifetime sexual partners, any tobacco use, and whether there has been any vaccination against HPV. Details about menstrual patterns, abnormal bleeding, persistent vaginal discharges, irritations, and known cervical lesions should also be disclosed.
During physical examination, the doctor will evaluate both the external and internal genitalia. Some women might display certain signs, like a fragile cervix, visible cervical lesions, erosions, masses, bleeding during the examination, and fixed adnexa, which are structures next to the uterus. However, many women with cervical cancer might not show any noticeable signs during the physical examination. Therefore, regularly screening tests like Pap smear and/or HPV testing are critical for early detection and treatment of cervical cancer and its precursor conditions.
- Complete sexual history
- First sexual encounter
- Post-intercourse bleeding or discomfort
- Past STIs, including HPV and HIV
- Number of lifetime sexual partners
- Tobacco use
- Prior vaccination against HPV
- Menstrual patterns
- Abnormal bleeding
- Persistent vaginal discharges, irritations, known cervical lesions
- Evaluation of external and internal genitalia
- Screening tests like Pap smear and/or HPV testing
Testing for Cervical Cancer
The United States Preventative Services Task Force (USPTF) suggests that women should start Pap screening at age 21. From age 30, HPV testing should begin along with Pap smear cytology. This screening should be done every three years if previous results were negative or if women are at low risk of cervical cancer. From age 30 onwards, Pap smear cytology can be carried out every five years with HPV testing, especially for women with a low risk of cervical cancer and consistently negative results. The USPTF recommends stopping these tests at age 65 for such cases. If a woman has undergone a full abdominal hysterectomy, involving the removal of the cervix for non-cancerous reasons, further screening isn’t necessary.
For abnormal cytology or persistent high-risk HPV infection, colposcopy is the preferred diagnostic test. This procedure closely examines the cervix, and the American Society for Colposcopy and Cervical Pathology (ASCCP) provides guidelines for when it should be carried out and is considered a standard procedure. You may need multiple colposcopy-guided biopsies and samples from the inner cervix, except during pregnancy. Abnormal colposcopy results could include changes in the color of the cervix when acetic acid is applied, excessive blood vessels, unusual vessels, a mosaic pattern, and small, red or brown spots.
If you have been diagnosed with invasive cervical cancer, a complete staging workup is required. The International Federation of Gynecology and Obstetrics (FIGO) has developed a staging system using multiple methods based on the local extent of the tumor. In the past, this might involve pelvic examination, cystoscopy, proctoscopy, chest x-ray, intravenous pyrography, and basic labs. Nowadays, advanced imaging techniques like MRI and PET scans are often used. Pelvic MRI is excellent for detecting local tumor growth and can be used to monitor the tumor’s response. PET scans are better than CT scans at detecting nodal and visceral metastases, as the presence of disease in the lymph nodes can significantly impact prognosis.
Treatment Options for Cervical Cancer
For women under 25 years old, potentially cancerous lesions are usually handled with care. Most of the abnormalities found in this age group are low-risk changes in the cervix, which often get better on their own. For persistent abnormalities or lesions that are suspected to be medium or high risk, a procedure called colposcopy is used. The management of these lesions is based on what the procedure finds.
Less serious lesions are typically watched closely and checked more often. More serious lesions are treated depending on their size, how deep they are, and where they are located. For lesions that are relatively small and shallow, a procedure called cryotherapy or an excision (removal) procedure may be used. For lesions that are more extensive and include the canal within the cervix, procedures such as a cone-shaped excision (conization), laser surgery, or LEEP (a procedure that uses a thin, low-voltage electrified wire loop) might be used. LEEP may help to see the junction between the outer and the inner lining of the cervix better and cause less bleeding when performed in an outpatient setting.
If cancer is identified, the next step is to find out how far it’s advanced, to decide on the best treatment options. The stage of cancer is determined by the symptoms, physical examination, results from microscopic examination of tissue (pathology), and imaging tests. Further, grading is based on the size and depth of the cancer and signs of spreading to other organs. The usual treatment for early-stage cancer is surgery, which might range from conisation to extensive surgery called a modified radical hysterectomy. Women with high-risk pathologies after surgery might have to undergo additional treatment with drugs and radiation. Options like a conisation or trachelectomy (removal of the cervix) might be suitable for women with early-stage cancers who wish to preserve fertility. For patients with advanced cancers, a combination of chemotherapy and radiation is standard.
What else can Cervical Cancer be?
It’s important to check any visible changes or growths in the cervix for cancer. However, most of the time, cervical cancer doesn’t cause any symptoms or show up as an obvious lump in its early stages. There are also other reasons for changes in the cervix or unusual bleeding. These could be sexually transmitted infections, harmless lumps called polyps or fibroids, or a condition where tissue similar to the lining of the womb starts to grow in other places called endometriosis.
To figure out if the condition is cervical cancer or something else, doctors may need to look more closely at the symptoms and carry out some tests. A more detailed look at the tissue might be necessary to confirm if it’s cancer.
There are other conditions that can look a bit like cervical cancer, including a rare form of cancer that affects the womb and placenta, a type of tumor that can look like cancer but isn’t, or even a cancer that’s started somewhere else in the body and then spread to the cervix. It’s also worth noting that sometimes, a regular cervical screening test could accidentally find a cancer that’s spread to the cervix.
Surgical Treatment of Cervical Cancer
If a patient has early-stage cervical cancer that is still only in the cervix, surgery is usually the chosen treatment. Surgery can range from less invasive procedures like cervical conization, which removes a small portion of the cervix, to larger operations such as a radical hysterectomy, which involves removing the entire cervix and surrounding tissue. Surgery is particularly important for younger patients who may want to maintain their ability to have children.
There are several types of surgery that can be used to treat cervical cancer. Each type is selected based on factors like the stage of the cancer and the patient’s desire for future fertility.
Cervical conization, for example, is typically used for patients with the earliest stages of cervical cancer. The procedure involves using a scalpel or a laser to remove a small cone-shaped area of the cervix. If further examination of the removed tissue shows signs of the cancer spreading, a more invasive surgical treatment may be needed.
Radical trachelectomy is another surgery that is suitable for patients who still want to have children in the future. This operation involves removing most of the cervix and preserving a small section for future pregnancy. After the operation, doctors typically check the lymph nodes for signs of cancer spread.
There are two types of hysterectomy used in treating cervical cancer. An extrafascial hysterectomy removes the entire cervix and uterus, and is typically offered to patients who do not wish to have children in the future. In a radical hysterectomy, more surrounding tissue is removed, and it is commonly performed in almost all early-stage cervical cancer cases when fertility preservation is not desired.
A type of surgery known as laparoscopic radical hysterectomy involves smaller incisions and a quicker recovery, but this procedure has been largely abandoned due to poorer outcomes compared to traditional surgery.
Pelvic exenteration, the most radical surgical procedure for cervical cancer, is only used for specific cases of recurrence or advanced disease, involving removal of various pelvic organs. It highlights the complexity and variety in surgical treatment options for cervical cancer.
Diagnosing and treating cervical cancer during pregnancy presents unique challenges. Pregnant patients should be evaluated by maternal-fetal medicine specialist to discuss potential risks to both the mother and baby.
A patient’s treatment often has to be individualized and is typically discussed by a multidisciplinary team of doctors. For instance, patients early in their pregnancy and with early-stage disease can be treated with conization, while patients with pregnancies beyond 22 weeks and early-stage disease may delay treatment until after delivery. Patients with advanced disease may receive chemotherapy until delivery, followed by cesarean radical hysterectomy.
It’s important to note that immediate treatment is recommended for patients with documented lymph node metastasis, disease progression, or pregnancy termination. In these cases, the treatment recommendations are similar to those of a non-pregnant patient.
What to expect with Cervical Cancer
Several factors influence the recovery of patients with cervical cancer. Key factors that could affect prognosis are the stage of the disease, the number of lymph nodes identified during treatment, the use of a uterine manipulator during laparoscopic treatment, age, race, general health before diagnosis, and access to the correct treatment methods. Understanding these elements can help find ways to improve patient care and reduce mortality rates.
If caught early, the 5-year relative survival rate for cervical cancer can be about 92%. However, only 44% of cervical cancer patients are diagnosed at this early stage. Missing regular health screenings can often lead to late diagnosis. The survival rate drops if the cancer has already spread at the time of diagnosis; it’s 60% if it has spread locally or to regional lymph nodes and only 19% if it has spread more distantly.
Some aspects of surgical treatment can also affect survival rates. For instance, removing a higher number of lymph nodes during treatment can lead to better patient outcomes. If a uterine manipulator is used during laparoscopic surgery, this also tends to be linked to a better prognosis.
The survival rates can also vary based on race. The 5-year relative survival rate for all women is 67%, but black women tend to have the highest mortality rates and the lowest survival rates; their 5-year relative survival rate is around 56%.
Patient’s age at diagnosis also affects the prognosis independent of the disease stage and type. Older patients generally have lower survival rates. Those under 50 years of age have a 5-year survival rate of around 77%, which drops to 61% for those aged 50 to 64, and 46% for those aged 65 and older. Despite this, even older women can still significantly benefit from appropriate treatment.
Possible Complications When Diagnosed with Cervical Cancer
In advanced stages of the disease, similar to other types of cancer, there may be a range of complications related to the disease itself and the treatments used. Some of the possible late-stage complications include:
- Renal failure (kidney failure)
- Hydronephrosis (swelling of a kidney due to a build-up of urine)
- Pain
- Lymphedema (swelling caused by a blockage in the lymphatic system)
- Bleeding disorders
- Fistulas (an abnormal connection between two body parts)
Please see the attached image for an example of Secondary Lymphedema.
Preventing Cervical Cancer
Teaching patients about cervical cancer in traditional and creative ways can help raise general awareness about the disease and highlight the importance of preventative measures and early checks. Research indicates that medical professionals don’t always consistently advise or talk about the HPV vaccination with the patients who need it. Some women and parents might have concerns about vaccinations which prevent them from getting vaccinated. Extra training for healthcare professionals who work with high-risk groups could raise awareness and encourage prevention of the disease and more regular checks in patients most likely to die from the disease.
While a patient might prefer to get advice directly from their doctor, it is also necessary to reach out to the wider community. Information that takes into account different cultures, using language that is easy to understand, and efforts specifically targeting women who are not sexually active are all ways to increase awareness and education about the disease and to expand checks outside of doctors’ offices.