Adequate cervical cancer treatment now makes cervical cancer screening critical. It is easily curable in the initial cervical cancer stages. Learn more.

Cervical Cancer

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Cervical cancer is defined as a cancerous change in the cells lining the cervix, which connects the uterus and the vagina.

Cervical cancer is a type of cancer that occurs in the cells lining the cervix (the connection between the uterus and the vagina). Cervical cancer can also affect the deeper cervix tissues and spread to other parts of the body, such as the vagina, rectum, bladder, liver, and lungs. Most cervical cancers are caused by various strains of the sexually transmitted human papillomavirus. Typically, the body&rsquo;s immune system, when exposed to HPV, prevents the virus from causing any harm. However, the virus may survive for years in a small percentage of people and cause the cervical cells to become cancer cells.&nbsp; 
&nbsp;

Cervical cancer is the fourth most common cancer in the world. In 2020, WHO reported 604,000 new cases and 342,000 deaths because of cervical cancer in low- and middle-income countries<a href="#accordion">[1]</a>. In addition, women with HIV are 6 times more likely to develop cervical cancer. HIV is attributed to 5% of all cervical cancer cases<a href="#accordion">[2]</a>. Cervical cancer grows slowly. Therefore, in high-income countries, the incidence of cancer is lower because of vaccination and screening programs that allow women to get screened for HPV regularly. Moreover, the cancer is treated before it causes serious problems. However, in low- to middle-income countries, there is a lack of access to this preventative measure, and the cancer is often not identified till symptoms present and it has reached an advanced state.&nbsp;

 
Additionally, there are limited treatment options, for example, chemotherapy, radiotherapy, and cancer surgery in low-income countries, which results in a higher number of deaths from cervical cancers. However, the exact prevalence of cervical cancers is not known in Pakistan because of inconsistent epidemiological data<a href="#accordion">[3]</a>. In 2002, the prevalence of cervical cancers in Pakistani women was 0.0009%, while in 2008, the prevalence increased to 0.019%<a href="#accordion">[3]</a>. In recent years, the incidence of cervical cancer in Pakistan has risen significantly, with the highest female mortality rates. Women between the ages of 35 and 44 years are most likely to get affected by cervical cancer, and more than 15% of new cases are reported in women over the age of 65, despite the absence of regular screening.

&nbsp;

Cervical cancers and pre-cancers can be classified into two main types, squamous cell carcinoma, and adenocarcinoma.&nbsp;

&nbsp;

<ul dir="ltr">
	<li>Squamous Cell Carcinoma&nbsp;account for 9 out of 10 cervical cancers. Cervical squamous cell carcinomas develop from cells found in tissue lining the outer part of the cervix, or the exocervix. These carcinomas often begin where the exocervix joins the endocervix, the inner part of the cervix that forms a canal and connects the vagina to the uterus.&nbsp;</li>
</ul>

&nbsp;

<ul dir="ltr">
	<li>Adenocarcinoma&nbsp;is a cancer that develops in the glandular cells that produce mucus. The inside passage of the cervix that runs from the cervix to the uterus is lined with glandular cells that produce mucus. The cancer is less common than squamous cell carcinoma.&nbsp;</li>
</ul>

&nbsp;

<ul dir="ltr">
	<li>Adenosquamous Carcinoma Or Mixed Carcinoma has features of both squamous and glandular cells. This is a rare type of cervical cancer and only 5% to 6% of cervical cancers are of this type. Other types of cancers that can develop in the cervix include melanoma, lymphoma, and sarcoma. However, these cancers are rare and more commonly occur in other parts of the body.</li>
</ul>

&nbsp;

Signs And Symptoms

The symptoms of cervical cancer do not usually appear until the cells become cancerous and invade nearby tissues. Common symptoms of cervical cancer include:&nbsp;

<ul>
	<li>Abnormal bleeding that may start and stop between regular menstrual periods.&nbsp;</li>
	<li>Vaginal bleeding may occur after sexual intercourse, a pelvic exam, or douching.&nbsp;</li>
	<li>Watery and bloody vaginal discharge with a foul odor.&nbsp;</li>
</ul>

&nbsp;

Other symptoms of cervical cancer may include:&nbsp;

<ul>
	<li>Heavier menstrual bleeding that may last longer than usual</li>
	<li>Bleeding after menopause&nbsp;</li>
	<li>Increased vaginal discharge&nbsp;</li>
	<li>Pain during intercourse&nbsp;</li>
</ul>

&nbsp;

If cancer has metastasized and spread to nearby tissues or organs, the symptoms may include:&nbsp;

<ul>
	<li>Difficult or painful urination with blood in the urine&nbsp;</li>
	<li>Diarrhea, pain, or rectal bleeding</li>
	<li>Loss of appetite and weight&nbsp;</li>
	<li>Fatigue&nbsp;</li>
	<li>Malaise or a general feeling of illness&nbsp;</li>
	<li>Swelling in the legs&nbsp;</li>
	<li>Dull backache&nbsp;</li>
	<li>Pelvic and abdominal pain&nbsp;</li>
</ul>

The symptoms of cervical cancer may mimic other medical problems and conditions. Therefore, it is important to consult a doctor for an accurate diagnosis.

&nbsp;

Causes

Cervical cancer is characterized by changes or mutations in the DNA of the healthy cells in the cervix. The function of the cell&rsquo;s DNA is to tell the cell what to do. For example, healthy cells grow and multiply at a set rate and the cells are programmed to eventually die at a set time. However, the mutation causes these cells to grow and multiply without programmed cell death. The accumulating abnormal cells form a tumor and invade nearby tissues and can spread elsewhere in the body.&nbsp; 
&nbsp;

While it is not clear what causes cervical cancer, HPV, a sexually transmitted virus plays a role. HPV is a common sexually transmitted virus, but most people with the virus do not develop cancer. Other factors cause the virus to lead to cancer development, for example, the environment and lifestyle choices. The virus transmits through sexual contact, anal, oral, or vaginal. Most people will get HPV at some point in their lives, but not realize it because the body fights the infection. However, if the body does not fight the infection, it can cause cancerous changes in the cells of the cervix.&nbsp;

There are 100 different kinds of HPV, out of which, a dozen have been shown to cause cancer. Early detection of HPV and regular screenings are key to preventing cervical cancer. Regular screenings with the healthcare provider will help identify precancerous changes or unusual changes in the cells of the cervix. In addition, the HPV vaccine can help protect against the virus that causes 90% of all cervical cancers.

&nbsp;

Cervical cancer screening aims to detect precancerous changes in the cervix. Regular cervical screenings can help significantly decrease the number of deaths because of cervical cancer. Your healthcare provider may suggest a combination of tests to detect HPV infection:&nbsp;

&nbsp;

<ul>
	<li>Pap Test: The test detects abnormal cells in the cervix.&nbsp;</li>
	<li>HPV Test: The test will detect high-risk HPV infection types that are likely to cause cervical cancer.&nbsp;</li>
</ul>

&nbsp;

Stages of cervical cancer:

<ul>
	<li>Stage I: Stage I cervical cancer is only found in the cervix, is small, and has not spread.&nbsp;</li>
	<li>Stage II: Stage II cervical cancer has spread beyond the cervix and uterus, but has not spread to the pelvic wall or the vagina.&nbsp;</li>
	<li>Stage III: In stage III of cervical cancer, cancer has spread to the lower part of the vagina, and may have spread to the uterus, pelvic wall, and lymph nodes.&nbsp;</li>
	<li>Stage IV: Cancer has spread to the bladder, rectum, and other parts of the body, such as the bones or <a href="https://merisehat.pk/disease/lung-cancer-67">lungs</a>.&nbsp;</li>
</ul>

&nbsp;

<h5>Routine Pelvic Exams&nbsp;</h5>

Based on the health history and sexual activity of an individual, the healthcare provider will decide whether a pelvic exam is needed when cervical cancer screening is not available. Therefore, it is important to schedule routine visits with your healthcare provider to discuss concerns specific to your sexual and reproductive health. If you are under the age of 25 and sexually active, regular screenings of chlamydia and gonorrhea are recommended. In addition, a clinical breast exam will help with the early detection of lumps on your breasts.

&nbsp;

Diagnosis

Cervical cancers develop over many years. Before turning to cancer, the cells of the cervix will undergo several abnormal changes. Similarly, in some cases, the irregular and abnormal cells may stay the same or go away and not turn into cancer cells. Regular screenings with a Pap smear can help detect cervical cancer. The Pap smear will collect cells from the cervix and examine them for signs of irregularities.&nbsp;

If the results of the Pap smear come back as abnormal, the doctor will recommend further testing which may include an HPV test. The specific test will check the cells of the cervix for HPV infection. There are certain types of HPV that are linked with cervical cancer. If cancer is suspected, your doctor will examine the cervix and biopsy some cells or tissue for examination. The biopsy tissue can be obtained with many techniques, for example, punch biopsy, or endocervical curettage.&nbsp;

&nbsp;

Tests For Cervical Cancer

The tests used for detecting cervical cancer include Pap tests and tests for HPV. Cervical cancer screenings are to detect precancerous or abnormal cells. When the cells are detected early, the cancer is less likely to become serious and is easily treatable. The healthcare provider will perform a Pap smear or HPV test using a swab or a scrape of your cervix to collect cells.&nbsp;

<ul>
	<li>Conization &ndash; In this procedure, a part of the cervix is removed under general anesthesia, using a scalpel or a laser.&nbsp;</li>
	<li>Colposcopy &ndash; A colposcopy is a pelvic exam that the doctor may recommend if the Pap smear shows abnormal growth. The cervix is stained with a harmless dye or acetic acid, so the cells are easier to see, and a microscope is used to look for unusual cells for biopsy. Another biopsy may be needed if the colposcopy shows signs of invasive cancer.&nbsp;</li>
	<li>Loop Electrosurgical Procedure (LEEP) &ndash; In LEEP, an electrified loop of wire is used to take a sample of tissue from the cervix, to examine the unusual cells in your cervix.&nbsp;</li>
</ul>

&nbsp;

Further tests will be recommended if the biopsy confirms cancer, these tests may include:&nbsp;

<ul>
	<li>Liver and kidney function tests&nbsp;</li>
	<li>Blood tests to check whether the cancer has spread to the liver</li>
	<li>CT scan to see if the cancer has metastasized</li>
	<li>Urine test and cystoscopy to check the bladder and urethra</li>
	<li>Colposcopy of the vagina&nbsp;</li>
	<li>Barium enema and proctosigmoidoscopy to check the rectum&nbsp;</li>
	<li>X-ray of the chest, bladder, abdominal cavity, bowels, and rectum&nbsp;</li>
	<li>CT, MRI, and PET scans of the lymph nodes</li>
</ul>

&nbsp;

Treatment

&nbsp;

<ul>
	<li>
	<h5>Precancerous Lesions&nbsp;</h5>
	</li>
</ul>

Low-grade lesions may not require treatment. The precancerous area is destroyed with LEEP conization, cauterization, and cryosurgery, with limited damage to the surrounding healthy tissue. Other options include laser ablation, which destroys the cells in the area or layers of cervical tissues. The doctor will order a follow-up exam and Pap smear after cryotherapy, cauterization, or laser therapy to ensure that all the precancerous cells are gone.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Invasive Cervical Cancer&nbsp;</h5>
	</li>
</ul>

Treatment for invasive cervical cancer includes surgery and radiation therapy. Others include chemotherapy and biological therapy. If the cancer is superficial, the doctor can destroy the cancerous cells with LEEP or cold knife conization. However, if the cancer has spread to surrounding tissue and invaded the deeper layers of the cervix, the tumor may need to be removed with surgery. If the cancer has spread to the uterus, the doctor may recommend a hysterectomy (a surgical procedure to remove the uterus).&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Radiation Therapy&nbsp;</h5>
	</li>
</ul>

Radiation therapy or radiotherapy uses high-energy rays to damage the cancer cells, only in the treated area, and stop their growth. The treatment may be external, internal, or both. In external radiation, a large machine is used to aim radiation at the pelvis. The procedure takes a few minutes and is repeated 5 days a week for 5 to 6 weeks.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Internal Radiation&nbsp;</h5>
	</li>
</ul>

Internal radiation, also known as implant radiation or brachytherapy is done using a capsule containing radioactive material that is put in the cervix to kill the cancerous cells while sparing the surrounding healthy tissue.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Chemotherapy&nbsp;</h5>
	</li>
</ul>

Chemotherapy is a cancer treatment in which powerful drugs are used to kill cancer cells. Chemotherapy drugs are often used for the treatment of locally advanced or metastasized cervical cancer. Moreover, the treatment is done in cycles of intensive treatment in an outpatient clinic, followed by recovery periods.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Biological Therapy Or Immunotherapy&nbsp;</h5>
	</li>
</ul>

This type of treatment targets immune cells to set off an immune response. The immune system is made up of white blood cells, organs, and tissue of the lymph system to help fight infections. Biological therapy and immunotherapy can be used to block the protein on the tumors to slow their growth.&nbsp; 
&nbsp;

<ul>
	<li>
	<h5>Surgery&nbsp;</h5>
	</li>
</ul>

There are different types of surgeries used for the treatment of cervical cancer. The most common kinds of surgeries for cervical cancer include:&nbsp;

<ol>
	<li>Laser Surgery &ndash; Laser surgery uses a laser beam to destroy the cancer cells.&nbsp;</li>
	<li>Cryosurgery &ndash; Cryosurgery freezes the cancer cells.&nbsp;</li>
	<li>Cone Biopsy &ndash; In cone biopsy, a cone-shaped piece of tissue is removed from the cervix.&nbsp;</li>
	<li>Simple Hysterectomy &ndash; In this surgery, the uterus is removed, but not the tissue next to the uterus. The lymph nodes in the vagina and pelvic area are also not removed.&nbsp;</li>
	<li>Radical Hysterectomy With Pelvic Lymph Node Dissection &ndash; In a radical hysterectomy, the uterus, surrounding tissue, cervix, and a small portion of the upper vagina and pelvic lymph nodes are removed.&nbsp;</li>
	<li>Trachelectomy&nbsp;&ndash; In this procedure, the cervix and the upper part of the vagina are removed.&nbsp;</li>
	<li>Pelvic Exenteration &ndash; Pelvic exenteration is similar to a radical hysterectomy&nbsp;but also includes the bladder, vagina, rectum, and part of the colon, where cancer has spread.</li>
</ol>

&nbsp;

Complications of cervical cancer can range from minor and severe to life-threatening. The complications can arise as side effects of treatment or as a result of the cancer. Complications of cervical cancer may include:&nbsp;

<ul>
	<li>Bleeding from the vagina&nbsp;</li>
	<li>Frequent urge to urinate&nbsp;</li>
	<li>Severe bleeding&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/kidney-stones-66">Kidney failure</a></li>
</ul>

&nbsp;

The risk factors of cervical cancer in Pakistan include uncircumcised partners, perineal hygiene (washing the genital and rectal areas), choice of contraceptive, and age<a href="#accordion">[3]</a>. Other risk factors that may increase the risk of developing cervical cancer include:&nbsp; 
&nbsp;

<ul>
	<li>HPV &ndash; Human papillomavirus (HPV) is a sexually transmitted disease with 100 different types, around 13 of which are known to cause cervical cancer.&nbsp;</li>
	<li>Multiple Sexual Partners Or Being Sexually Active At An Early Age &ndash; The transmission of the virus mostly occurs because of sexual contact with an individual who has HPV. Similarly, women who have had many sexual partners are at a higher risk of contracting HPV infection, which further increases the risk of developing cervical cancer.&nbsp;</li>
	<li>Smoking &ndash; Smoking increases the risk of all types of cancers.&nbsp;</li>
	<li>Immunocompromised &ndash; People with HIV or AIDS, those who have undergone transplants and are using immunosuppressive drugs are at a higher risk of developing cervical cancer.&nbsp;</li>
	<li>Contraceptive Pills &ndash; Long-term use of birth control pills can increase the risk of cervical cancer.&nbsp;</li>
	<li>Sexually Transmitted Diseases (STDs) &ndash; Other STDs, for example, <a href="https://merisehat.pk/disease/syphillis">syphilis</a>, <a href="https://merisehat.pk/disease/gonorrhea">gonorrhea</a>, and chlamydia can increase the risk of cervical cancer.&nbsp;</li>
	<li>Socio-Economic Status &ndash; The incidence of cervical cancer is higher in low-income areas.</li>
</ul>

&nbsp;

Several measures can prevent cervical cancer, but the key to preventing aggressive cancer is through screening. Screening can help detect cell changes early or in the precancerous stage. Other preventive measures include:&nbsp;

<ul>
	<li>The CDC recommends that if you&rsquo;re 21 years or older, get a Pap smear done every 3 years.&nbsp;</li>
	<li>If you are between 30 and 65 years, both Pap smear and HPV tests are recommended every 5 years. However, if you are at low risk of developing cervical cancer, the doctor may be able to stop testing.&nbsp;</li>
	<li>Women who don&rsquo;t have a history of cervical cancer or precancerous lesions, or have had their cervix removed, don&rsquo;t need screening.&nbsp;</li>
	<li>If you are sexually active, have a history of STDs, or have a higher risk of developing STDs, get tested for chlamydia, syphilis, and gonorrhea every year. In addition, if you are at high risk, get tested for HIV at least once a year.&nbsp;</li>
</ul>

&nbsp;

Steps to prevent HPV infection include:&nbsp;

<ul>
	<li>Use a barrier, such as a condom if you are sexually active.&nbsp;</li>
	<li>Get vaccinated for HPV. HPV causes 70% of cervical cancers and over 50% of precancerous lesions of the cervix or vagin<a href="#accordion">[4]</a>.&nbsp;</li>
	<li>Smoking also raises the risk of developing cervical cancer. Therefore, quitting smoking can lower the risk.&nbsp;</li>
	<li>A hysterectomy will also lower the odds of getting cervical cancer. In this procedure, the doctor removes the uterus, but you cannot become pregnant afterward because your reproductive organs are removed.</li>
</ul>

&nbsp;

Key Points

<ul>
	<li>Cervical cancer is a cancerous change in the cells lining the cervix. Cancer can also affect the deeper cervix tissues and spread to other parts of the body, such as the vagina, rectum, bladder, liver, and lungs.</li>
	<li>Cervical cancer is the fourth most common cancer in the world. In 2020, WHO reported 604,000 new cases and 342,000 deaths because of cervical cancer in low- and middle-income countries. In recent years, the incidence of cervical cancer in Pakistan has risen significantly with the highest female mortality rates. However, in Pakistan, the true prevalence of cervical cancers is inconclusive.&nbsp;&nbsp;</li>
	<li>The tests used for detecting cervical cancer include Pap tests and tests for HPV. If the results of the Pap smear come back as abnormal, the doctor will recommend further testing which may include an HPV test and biopsy.&nbsp;</li>
	<li>The risk factors of cervical cancer in Pakistan include uncircumcised partners, perineal hygiene (washing the genital and rectal areas), choice of contraceptive, and age.&nbsp;</li>
</ul>

&nbsp;

[1] World Health Organization. 2022. Cervical Cancer.

[2] Stelzle, D., Tanaka, L.F., Lee, K.K., Khalil, A.I., Baussano, I., Shah, A.S., McAllister, D.A., Gottlieb, S.L., Klug, S.J., Winkler, A.S. and Bray, F., 2021.