What is Cervical Squamous Cell Carcinoma?
Cervical cancer, a type of cancer that starts in the cervix, is the fourth most common cancer among women, following breast, lung, and colorectal cancer. The cervix is the lower part of the uterus that connects to the vagina. Despite its prevalence, cervical cancer is easily preventable due to Papanicolaou smear screening or the commonly called Pap smear. This screening helps in early detection of cells that may potentially turn into cancer, allowing them to be removed before they evolve into a serious condition. However, in women from low and middle-income countries, it is still a common issue because extensive screening is lacking. Cervical cancers usually develop from squamous-cell carcinomas, a type of skin cell, and are often caused by infection from specific types of Human Papilloma Virus (HPV), such as HPV 16 and 18.
The cervix, along with the fallopian tubes, uterus, and the upper portion of the vagina comes from something called the paramesonephric duct when a female baby is developing. The cervix itself is cylindrical and has an interior cavity known as the cervical canal, which links the uterus and the vagina. The part of the cervix that sticks out into the vagina separates it into an upper part and a vaginal part. The upper part is sandwiched between the bladder, the intestines and rectum, and the uterine artery and ureter. Meanwhile, the cervical canal and vagina encase the vaginal part of the cervix.
If we look deeper into the cervix, it’s composed largely of a type of connective tissue that’s flexible and elastic. There are three parts to it; the endocervix, a transformation zone, and the ectocervix. The endocervix has column-like cells that produce a substance called mucus, and the ectocervix comprises of layered skin-like cells. The point at which these two types of cells meet is called the transformation zone. Most cervical cancers occur in this area. The cervix’s blood supply comes from the uterine artery while the lymphatic drainage, which is the body’s waste disposal system, heads towards specific lymph nodes.
Thanks to screening programs, the number of cervical cancer cases has been decreasing significantly, especially in areas where these programs are well-established. Despite this improvement, around 70 percent of the current cases of cervical cancer still come from areas where people are generally poorer and screening programs are not effective. It often affects women who have multiple sexual partners and do not use condoms, as this increases the risk of HPV infection. HPV can alter the cells in the transformation zone of the cervix, and over time this might lead to abnormal cell growth, a condition known as cervical intraepithelial neoplasia (CIN). Though CIN can evolve into cervical cancer, in some cases it might also clear up on its own. The potential for CIN to turn into cancer differs from person to person.
Not every woman infected with HPV will develop CIN. In most cases, the body’s immune system successfully fights off the HPV infection. Certain factors can increase the risk of developing CIN, such as the type of HPV contracted, how long the infection lasts, environmental factors like smoking, and a weakened immune system. Luckily, there is a vaccine available that can offer protection against several types of HPV, including the ones that increase the risk of cervical cancer like HPV 16. Typically, cervical cancer affects women at a younger age compared to other cancers, with the average age of diagnosis being around 49. Most women with cervical cancer are diagnosed at an early stage and are cured, though they might experience side effects from the treatment, such as becoming infertile. Women who are diagnosed with advanced cancer or recurrent cervical cancer usually have a life expectancy of fewer than 2 years. The common spots for cervical cancer to spread are the lymph nodes, liver, lungs, and bones.
What Causes Cervical Squamous Cell Carcinoma?
Almost all women with cervical cancer (about 95%) have at least one type of human papillomavirus (HPV) infection. The most common types are HPV 16, found in 50% of women, and HPV 18, found in 10 to 15% of women.
There are two groups of HPV: high risk and low risk. High-risk HPVs like 16, 18, 31, 33, 35, etc., are linked with causing cancer, while low-risk ones, like 6, 11, 40, 42, and others, are typically not associated with cancer.
Not every woman who has an HPV infection will get cervical cancer. Many women have HPV 16 and 18 infections that don’t cause any symptoms and go away by themselves within two years. However, women who have HPV infections that don’t go away, and who also smoke cigarettes or have weak immune systems, are more likely to get cervical cancer.
In addition to HPV infections, other factors also contribute to the development of cervical cancer. One of these is the exposure to tar, which can come from sources like cigarette smoke, certain vaginal cleaning products, and fumes from burning materials like wood, dung, or coal in poorly ventilated areas.
Some other factors that make a woman more likely to get cervical cancer include having sex at a young age, having multiple or high-risk sexual partners, having a weak immune system due to HIV or other viral infections, using oral contraceptives and progestogen, being poor or having poor personal hygiene, and using tobacco.
Risk Factors and Frequency for Cervical Squamous Cell Carcinoma
Cervical cancer is the fourth most common type of cancer affecting women all over the world. In 2018 alone, around 569,847 women were diagnosed with it, leading to 311,365 deaths. These statistics make cervical cancer the fourth deadliest cancer affecting women.
Around 84% of cervical cancer cases occur in economically disadvantaged regions. This is because developed countries have access to PAP smear tests and HPV vaccination, which have helped to decrease the number of cervical cancer cases by 75% over the last 50 years. In developing countries, cervical cancer is the second most common cancer and the third most deadly cancer affecting women.
In the United States, cervical cancer is the third most common and deadly cancer affecting women’s reproductive organs.
There are differences in the rate of cervical cancer between different racial groups. For example, a US study found that black women have higher rates than white women.
- Hispanic/Latino women: 9.6 cases and 2.6 deaths per 100,000 people.
- Non-Hispanic black women: 9.1 cases and 3.6 deaths per 100,000 people.
- American Indian/Alaska Native women: 8.7 cases and 2.5 deaths per 100,000 people.
- Non-Hispanic white women: 7.1 cases and 2.1 deaths per 100,000 people.
- Asian/Pacific Islander women: 6.0 cases and 1.7 deaths per 100,000 people.
Signs and Symptoms of Cervical Squamous Cell Carcinoma
Cervical cancer is a common disease in women who are 35 to 45 years old. There are certain behaviors and conditions that can increase the risk of developing cervical cancer. These include having a weak immune system, engaging in high-risk sexual behavior, having multiple sexual partners, a history of sexually transmitted diseases, and smoking. A lot of women with cervical cancer do not have any symptoms. But if symptoms do appear, they could include:
- Bleeding after sex or between menstrual cycles
- An increase in vaginal discharge
- Pain in the pelvic area or lower back
During a physical exam, the cervix might look normal or it may be inflamed or eroded and bleed upon touch. Swollen lymph nodes in the groin area may also be noticeable.
If cervical cancer spreads, it can cause more serious issues, such as:
- Hydronephrosis, which is swelling of a kidney due to a build-up of urine. This can happen if the cancer blocks the tubes that carry urine from the kidneys to the bladder.
- Swelling in the lower legs because the cancer compresses veins and lymph nodes in the pelvic area.
- // Swollen lymph nodes, abdominal, chest, or bone abnormalities (eg, pain) due to metastases to these regions
- Abdominal, chest, or bone pain caused by the cancer spreading to these areas.
- Heavy vaginal bleeding, which might occur in advanced stages of the disease.
Testing for Cervical Squamous Cell Carcinoma
Initial screening for cervical cancer involves three primary tests: cytology (cell studies), HPV testing (checking for the presence of human papillomavirus), and VIA (visual inspection with acetic acid). If any of these tests yield abnormal findings, the doctor may conduct a more detailed examination, called a colposcopy, and potentially will collect tissue samples for biopsy. This additional data confirms any abnormal results and aids in laying out a treatment plan.
Let’s break down each of these tests:
1. **Cervical Cytology (PAP Smear)**: This involves collecting cells from a particular region in your cervix. These cells are studied under a microscope to check for any abnormalities. Any abnormality may indicate a need for more tests.
Routine screening via a PAP smear is recommended for all women aged 21 to 65. Further recommendations depend on your age and health background. For example, women between 21 and 30 years may need PAP testing every three years. Between 30 and 65, a combined PAP and HPV test may be conducted every five years or only a PAP test every three years.
2. **HPV Testing**: This test is done to detect infections with high-risk HPV, which may cause cervical cancer. It is recommended for women who are 30 years and older as part of routine screening.
3. **Visual Inspection with Acetic Acid (VIA)**: The doctor will apply a 5% acetic acid solution to your cervix. This solution causes abnormal areas with more dense cellular material to turn white, while healthy cells don’t change color, assisting the doctor in identifying areas that might need to be biopsied.
4. **Colposcopy**: If results from the initial tests are abnormal, a colposcopy might be performed to have a closer look at your cervix. If any abnormal areas are identified, biopsies may be taken to further analyze the tissues.
The results from these screenings and tests will allow your healthcare provider to calculate a risk assessment to identify your immediate and 5-year risk of developing CIN 3+ (a high-grade cervical precancerous lesion). Based on this risk percentage, a suitable management plan will be determined.
Remember, guidelines for cervical cancer screening differ based on the resources available. The World Health Organization recommends a screen-and-treat approach using Visual Inspection with Acetic Acid (VIA), and treatment with cryotherapy or, when feasible, HPV testing followed by suitable treatment.
Treatment Options for Cervical Squamous Cell Carcinoma
There are three types of vaccines available to protect against the Human Papillomavirus (HPV), a common virus that can lead to certain types of cancer and other health problems. These vaccines can protect against different types of HPV: the Quadrivalent vaccine protects against types 6,11,16 and 18; the 9-Valent vaccine protects against types 6,11,16,18,31,33,45,52 and 58; and the Bivalent vaccine protects against types 16 and 18.
Both men and women should get the HPV vaccine to reduce the risk of health problems like genital warts, penile cancer, anal cancer, and the spread of the virus to sexual partners. However, it’s not advised for pregnant people because it’s unclear whether it’s safe during pregnancy. The vaccines generally work very well, with high rates of successfully producing antibodies (proteins that help fight off the virus) in the bodies of those getting the vaccine. These antibodies are more successful at younger ages. Side effects can include mild reactions at the injection site. The vaccine doesn’t get rid of existing HPV infections, warts, or changes to cells that can lead to cancer.
Experts from the Advisory Committee on Immunization Practices recommend the 9-valent vaccine as the most effective. It’s usually given in two doses six months apart if you are younger than 15, or three doses over six months if you are older than 15 or have a weak immune system. It’s best to get the vaccine before becoming sexually active, ideally around 11 to 12 years. For those aged 13-26 years who haven’t already been vaccinated can do so, however, it’s not usually recommended for people older than 26. For people over 26, it’s up to individual circumstances, particularly if they are at a high risk of catching HPV.
Studies have shown fewer instances of the cell changes that can lead to cancer in vaccinated people who’ve previously had these cell changes than in those who hadn’t been vaccinated. This shows the potential role of the vaccine in managing these potentially dangerous cell changes, and further investigation is needed.
To treat serious abnormal cell changes (Cervical Intraepithelial Neoplasia, also known as CIN 2 and CIN 3) doctors might use freezing or heat treatment to destroy abnormal cells, surgically remove these cells, or perform a hysterectomy. For invasive cervical cancer, treatment options depend on the stage of the cancer. They can include surgery, or a combination of radiation therapy and chemotherapy. For cancers that have come back after initial treatment or spread to other parts of the body, treatment can involve surgery, chemotherapy, or radiation therapy. The right treatment for each individual depends on various factors, including their overall health and the specific characteristics of the cancer.
What else can Cervical Squamous Cell Carcinoma be?
When a person shows symptoms that may indicate cervical cancer, there are several other similar conditions to consider also:
- Inflammation of the cervix (Cervicitis, particularly granulomatous)
- Inflammation of the vagina (Vaginitis)
- Inflammation of the uterus lining (Endometritis)
- Pelvic inflammatory disorder
- Uterus lining cancer (Endometrial carcinoma)
- Vaginal cancer
- Skin cancer or Paget disease in the genital area
Bleeding after sex is a common symptom of cervical cancer, but it can also be due to several other conditions, including:
- Infectious causes such as inflammation of the cervix, vagina, uterus lining, and pelvic inflammatory disease
- Non-infectious reasons such as other cancers in the female genital area, hormonal contraception which can change the pattern of bleeding, certain skin conditions, and injuries
If a patient reports bleeding after sex, the doctor will follow these steps to reach a diagnosis:
- History: Gather detailed information about the volume and frequency of bleeding and about menstrual cycles, pregnancy, contraception, sexual activity, and previous pap smear testing results.
- Physical Examination: Perform an examination to find the most likely source of the bleeding. This usually involves checking the external genitalia and urethra, the vagina and cervix, the uterus, and a general physical assessment.
- Lab Testing: Carry out lab tests based on the patient’s history and physical examination, which usually includes pregnancy tests, pap tests, biopsy tests, and testing for sexual infections.
- Colposcopy: Conduct a thorough examination of the cervix and vagina with a special magnifying device. This is done if the patient has a history of abnormal pap smear test results, if the cervix appears to be easily bleeding, or if no other cause of post-coital bleeding is identified.
- Imaging: Use imaging techniques like ultrasounds or hysteroscopy if the cause of bleeding is still not found. This helps to visually check the uterus and detect any abnormalities.
What to expect with Cervical Squamous Cell Carcinoma
There are various factors that can influence the survival outcomes in cases of cervical squamous cell carcinoma, which is a type of cervical cancer. These factors include:
* The stage of the cancer.
* If the cancer has spread to the lymph nodes.
* The size of the tumor.
* How far the cancer has invaded the cervix.
* Whether the cancer has spread to the blood or lymph vessels.
Of these factors, the most critical one is the stage of the cancer, followed by the status of the lymph nodes. Studies have found that among patients with the same stage of cancer (stage IB or IIA), those with lymph node metastases, meaning the cancer has spread to their lymph nodes, had lower 5-year survival rates (50 to 74%) after undergoing surgery to remove the uterus and lymph nodes. This compares to patients whose cancer had not spread to the lymph nodes (88-96%). Also, if the cancer has spread to the so-called para-aortic nodes, located near the aorta, the largest artery in the body, the patient’s outcomes are generally worse.
According to the 2018 version of the International Federation of Gynecology and Obstetrics (FIGO) cervical cancer staging system, the 5-year survival rates for different stages was calculated.
These are the 5-year overall survival rates:
* Stage IB1- 95.3%
* Stage IB2- 95.1%
* Stage IB3- 90.4%
* Stage IIA1- 92.4%
* Stage IIA2- 86.4%
* Stage IIIC1- 81.9%
* Stage IIIC2- 56.3%
This is how the 5-year rates where no cancer is found after initial treatment (progression-free survival rates) looked:
* Stage IB1- 94.0%
* Stage IB2- 91.0%
* Stage IB3- 88.5%
* Stage IIA1- 91.4%
* Stage IIA2- 86.4 %
* Stage IIIC1- 79.5%
* Stage IIIC2- 43.8%
It’s worth noting that patients who had 1-2 lymph nodes that tested positive for cancer had 5-year overall survival and progression-free survival rates of 86% and 84%, respectively. If more than 2 lymph nodes were cancerous, these rates dropped to 73.7% and 70.2%, respectively.
Possible Complications When Diagnosed with Cervical Squamous Cell Carcinoma
Cervical cancer can lead to several direct complications, such as:
- Hydronephrosis, which is caused by infiltration of the ureter leading to blockage in urine flow
- Fistula formations such as rectovaginal, vesicovaginal, or urethrovaginal, occur mainly in advanced cervical cancer cases
- Lower limb congestion caused by the compression of veins or lymphatics
- CACS, which stands for cancer-anorexia-cachexia syndrome. This means the patient suffers from weight loss, muscle atrophy, fatigue, weakness, and significant loss of appetite in someone who is not trying to lose weight
On the other hand, the treatment of cervical cancer is observed to improve quality of life, particularly after surgery or chemotherapy. However, treatment also comes with a risk of complications, including:
- Ovarian failure, which can result in infertility, early menopause, and sexual dysfunction
- Sexual dysfunction, including decreased vaginal lubrication and elasticity, orgasmic difficulties, changes in length and caliber of the vagina, dyspareunia (pain during sex)
- Disordered bowel or bladder function
- Risks involved with conization (a procedure to remove a cone-shaped piece of tissue from the cervix and cervical canal), including intraoperative or postoperative bleeding, infection, and uterine perforation, as well as late complications like cervical insufficiency and cervical stenosis
Preventing Cervical Squamous Cell Carcinoma
Educating patients is crucial for better disease management. For illnesses like cervical cancer, counseling is essential and should start from regular check-ups. Having a good relationship with your doctor allows you to express your worries and questions openly. Here’s what patients should know:
* The significance of Pap smear screenings: It’s important for women to understand the benefits of Pap smear tests. These tests can detect early changes in the cells of the cervix before they turn into cancer. Knowing about a problem early on means it’s more likely to be curable. It’s also important to understand that having cervical cancer at a later stage may require more aggressive treatment and result in worse outcomes.
* The value of HPV vaccination: HPV (Human Papillomavirus) vaccine is used to prevent cervical cancer as this virus is often the main cause of the disease.
* The pros and cons of getting treatment versus not getting treatment: Patients should understand their options, considering both the benefits and drawbacks, which can vary depending on each person’s situation.
* Risk factors for cervical cancer and prevention methods: Patients should learn about factors that may increase their risk of getting cervical cancer, and what actions can be taken to lower the risk.
Talking about concerns related to fertility and sexual function after treating cervical cancer is also important. It’s crucial for the patient to be informed and to discuss these matters with their healthcare provider.
