Cervical Cancer

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Cervical cancer is a type of cancer that forms in the cervix. The cervix is the opening of the uterus at the top of the vagina. Cancer develops when healthy cells change such that they grow and divide more rapidly. It is usually a slow-growing cancer that may be symptom less. Cervical cancer is almost always caused by a Human Papilloma Virus (HPV) infection.

HPV VACCINATION

The HPV vaccine protects against the specific types of HPV that are the most common cause of cancer, pre-cancerous conditions, and genital warts. The ideal age to receive the vaccination is 11 or 12 years, but it is administered between the ages of nine years through to 26 years. HPV vaccination has shown to decrease the incidence of high-grade cervical abnormalities and reduces the prevalence of the HPV types that specifically targeted by the vaccines. The effect of HPV vaccination on the incidence of cancer itself has not been clearly established but is expected to prevent up to 70% of cervical cancers.

TYPES OF CERVICAL CANCER

Cervical cancer may be classified in several ways by a doctor:

Based on types of cells in the tumour: It may be one of three categories: Squamous tumours (most common subtype begins in the thin, flat cells that line the cervix), Glandular tumours or adenocarcinoma (second most common and starts in the cells that produce mucus and other fluids), Other epithelial tumours (Rarer subtypes such as adenosquamous carcinoma, neuroendocrine etc.)

Based on how the disease has advanced:

      • Non-invasive cervical intraepithelial neoplasia: Cervical intraepithelial neoplasia (or CIN) is used to describe abnormal changes in the cells of the cervix. Although it is not cancer, it may progress to cancer in the future.
      • Early cervical cancer: Early cervical cancer is in conditions when the tumour has not spread beyond the cervix. The primary treatment is usually to remove the tumour surgically.
      • Locally advanced cervical cancer: When the cancer has spread outside the cervix into the surrounding tissues the treatment usually starts with chemotherapy and/or radiotherapy, but in some cases, surgery may be performed after the tumour has shrunk.
      • Metastatic cervical cancer: The cancer has spread to other parts of the body.

STAGING OF CERVICAL CANCER:

If you are diagnosed with cervical cancer, your doctor will run more tests to determine the extent (stage) of your cancer. Your cancer's stage is an important input in deciding on your treatment.

    • Stage I: In stage I, the cancer is restricted to the cervix only. It is divided into two stages: IA (Small amount of cancer is found in the tissues of the cervix only seen with a microscope) and IB (Maybe microscopic with increased depth or visible without a microscope). There is no spread to lymph nodes or to other parts of the body.
    • Stage II: The cancer has spread beyond the cervix but not to the pelvic wall or lower vagina. It is divided into (has spread to tissues around the cervix). It may or may not have spread to the lymph nodes but there is no spread to other parts of the body.
    • Stage III: In stage III, cancer has spread to the lower part of the vagina, and the pelvic wall. It may even cause kidney related problems. Stage III is divided into stages IIIA (The cancer has spread to the lower part of the vagina or the walls of the pelvis. The cancer may be blocking ureters, which are the tubes that carry urine from the kidneys to the bladder) and IIIB (The cancer has spread to the walls of the pelvis and/or is blocking one or both ureters leading to kidney-related problems). Lymph nodes may be involved but there is no spread to other parts of the body.
    • Stage IV: In stage IV, cancer has spread beyond the pelvis, in the lining of the bladder and/or rectum, or may have spread to other parts of the body. There are two subdivisions IVA (The cancer has spread to the bladder or rectum or it is growing out of the pelvis) IVB (The cancer has spread to distant organs beyond the pelvic area, such as distant lymph nodes, lungs, bones or liver.)
    • Recurrent Cervical Cancer: This is a form of cancer that has recurred after it being treated in the past.

Sources: European Society for Medical Oncology (ESMO); The American College of Obstetricians and Gynecologists (ACOG); American Cancer Society

SCREENING & DIAGNOSIS OF HPV

  • Screening Tests: Screening tests for cervical cancer involve taking a sample of cells from the cervix to check for signs of cancer. The Papanicolaou (Pap) test, was for a long time considered the standard method of screening in which cervical samples are checked for the abnormalities in the cervical cells. A sample of cells is collected from the surface of the cervix and vagina with a piece of cotton, a brush, or a small wooden stick and viewed under a microscope for abnormalities. The Pap test has greatly reduced the incidence and mortality due to cervical cancer. More recently, a new test has been introduced, which is more sensitive and is known as the HPV DNA screening test.
  • Clinical History & Examination: The clinician will ask for the presence of symptoms of cervical cancer (such as abnormal vaginal bleeding, pelvic pain, vaginal discharge, pain or discomfort during sex). A clinical examination will be carried out including looking at the cervix and vagina for abnormalities, an internal pelvic examination to check for lumps or other changes as well as examine the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum.
  • Colposcopy: If either a screening test is positive or symptoms and signs of cervical cancer are present, a colposcopy is conducted. This test allows the clinician to visualise the cervix in detail, and tissue samples of abnormal areas are taken.
  • Cone Biopsy: In this type of biopsy, a cone-shaped piece of tissue from the cervix is removed, under anaesthesia. It is examined under a microscope by a pathologist to check for abnormal cancer cells.
  • Radiological tests: Ultrasound uses high-energy sound waves to form a picture of body tissues and examine the abdominal and pelvic region. Chest x-ray is used to check the lungs and chest for the spread of cervical cancer. Intravenous pyelogram is an x-ray of the urinary tract taken with a special dye to identify any spread of cervical cancer in this region. Computed tomography (CT) scans are used to determine the extent of advancement of the cancer as well as to look for spread of the disease beyond the cervix. Magnetic resonance imaging (MRI) scans are useful due to their accuracy in determining the tumour size and spread of cancer. Positron emission tomography (PET) scan uses a radioactive substance injected into a vein which is particularly useful for detecting the spread of cancer to lymph nodes and other parts of the body.

TREATMENT OF CERVICAL CANCER

The management of cervical cancer depends on various factors, including the stage of the cancer, additional health issues, age etc. Surgery, radiation, chemotherapy or a combination may be used.

  • Surgery: The surgeons aims to remove the tumour as well as a healthy margin of tissue around it. Post-surgery, the tissue is examined under a microscope to ensure complete removal of the tumour. This may involve conisation (removal of a cone-shaped section of the cervix), hysterectomy (uterus and cervix completely removed) or trachelectomy (suitable for very early stage cancer in women who want to have children in the future. The cervix and upper section of the vagina removed, leaving the womb in place). Early-stage cervical cancer is typically treated with surgery to remove the uterus (hysterectomy). A hysterectomy can cure early-stage cervical cancer and prevent recurrence. But removing the uterus also leads to permanent infertility. The types of hysterectomy include Simple hysterectomy (Indicated in very early stage cervical cancer in which only the cervix and uterus are removed along with the tumour), Radical hysterectomy (Cervix, uterus, part of the vagina and lymph nodes are removed). Minimally invasive surgery may be an option for early-stage cervical cancer. Side effects: Side effects depend on the type of surgery but possible adverse effects may include: vaginal bleeding, irregular or painful periods, loss of bladder control, decreased sexual satisfaction, swelling of legs, vaginal prolapse, recurrence of cancer.
  • Radiation: This form of therapy uses high-powered energy beams to kill cancer cells. It is used alone or in conjunction with chemotherapy before surgery to reduce the size of the tumour or after surgery to destroy any remaining cancer cells. It is of two types: External beam radiation (the size of radiation is outside the body) or Internal radiation also known as Brachytherapy (a device filled with radioactive material is placed inside the vagina). Side effects: Skin changes, fatigue, skin irritation, bladder inflammation, vaginal bleeding, vaginal dryness, diarrhoea etc.
  • Chemotherapy: Chemotherapy uses medications to kill cancer cells. It is often combined with radiation therapy, to enhance the effects of the radiation. In incurable cervical cancers, higher doses of chemotherapy are used to control the disease. Side effects: Adverse effects depend on the drug used as well as the dose. Possible side effects include hair loss, thinning of bones, metallic taste in the mouth, blisters, low immunity, anemia, constipation, fatigue, vomiting, anorexia, joint and muscle pain.
  • Targeted Therapy: This form of therapy involves drugs that block specific chemical pathways in cancer cells, thus slowing down or halting growth. Side effects: diarrhoea, vomiting, nausea, fatigue, increased risk of bleeding, low immunity, skin reactions, hypertension, joint pain, nerve damage etc.
  • Supportive / Palliative care: Palliative care focuses on providing relief from pain and other symptoms. The main objective is to help cancer patients feel better and live longer and is provided alongside regular clinical care. In patients with advanced cervical cancer, this involves the management of pain, vaginal discharge, fistulae, bleeding, diarrhoea, incontinence, nutrition, and bedsores.

Sources: European Society for Medical Oncology (ESMO); National Cancer Institute; NHS; Mayo Clinic

MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:

  • Gynecologic oncologist: A trained surgeon who plays a key role in managing cervical cancer.
  • Medical oncologist: A doctor specializing in drug based treatments such as chemotherapy. 
  • Radiation oncologist: A clinician specialized in treating cancer with radiation
  • Pathologist/Onco-pathologist: A clinician specialized in examining tissue samples from the PAP smear and the biopsy under a microscope
  • Radiologist: A clinician specialized in reading X-rays, CT scans, MRIs, ultrasounds, and other imaging modalities.
  • Genetic Specialist: A clinician/scientist who determines the genetic make-up of a tumour.
  • Physiotherapist: Physical therapists provide support for patients, especially to alleviate the effects of some of the treatments for cancer.
  • Counsellor: Psychologist by training that offers counselling to patients
  • Dietician: Offers personalised support to cancer patients
  • Palliative care specialists: These professionals help patients and families deal with the emotions that come with a cancer diagnosis and cancer treatment such as anxiety and depression as well as keep the patient comfortable especially in incurable cases.

TUMOR BOARD: A tumor board is a meeting where your Multi-Disciplinary Team discusses cancer cases and shares knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.

In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient’s case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.

SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.

Sources: Patient Resource; Jostrust

Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile doctors and hospitals based on their range of services to treat cervical cancer. Use our search tools to find a suitable medical provider. You may get in touch with us for any assistance during selection or booking process.

If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For cervical cancer, you can start by visiting a medical oncologist or a surgical oncologist. Choose someone you are not only confident about but also comfortable with.

TIPS TO FIND AN ONCOLOGIST

  1. Look for Specialists: Look for doctors who treat your specific type of cancer - cervical You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
  2. Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
  3. Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for gynecological cancers, who have received dedicated training on treating cervical If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
  4. Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – cervical cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes.
  5. Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.

TIPS TO FIND A HOSPITAL 

  1. Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to cervical cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Find out if the hospital has a dedicated team for gynecological cancers? Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
  2. Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
  3. Research hospital’s Cervical Cancer volumes: How many cases of cervical cancer are treated in the hospital every year? High volume centers with multiple specialists available for gynecological cancers may have better expertise and specialized medical infrastructure required.
  4. Consider Clinical Trials Availability: Ask whether the doctor or hospital has access to clinical trials and if you are eligible for any. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients.
  5. Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.

Sources: Rogel Cancer Center; Cancer.Net

Section: Cervical Cancer Basics

How do Cancer cells behave differently from healthy ones?

Source: TEDed

Preventing Cervical Cancer, Pap test and HPV Test

Source: Nucleus Medical Media

Section: Tests for Cervical Cancer

Cervical Dysplasia , Pap Smear and Colposcopy

Source: Blausen Medical

Cervical Cancer Staging

Source: Nucleus Medical Media

TVUS - Transvaginal Ultrasound

Source: News Direct

CT Scan

Source: Nucleus Medical Media

MRI Scan

Source: Blausen Medical

PET CT Scan

Source: Blausen Medical

Section: Treatments for Cervical Cancer

Surgery, Chemotherapy & Radiation Therapy , Brachytherapy

Source: Nucleus Medical Media

Hysterectomy Surgery

Source: Covenant Health

Laparoscopic Hysterectomy
Key Hole Surgery

Source: Pawan Kumar Gupta

Chemotherapy

Source: Nucleus Medical Media

Radiation Therapy: What to Expect

Source: Accelerated Education Program

Radiotherapy

Source: Cancer Research UK

Brachytherapy

Source: Nucleus Medical Media

Radiation Sickness

Source: Blausen Medical

What is Palliative Care

Source: Get Palliative Care

What are Clinical Trials

Source: Cancer Research UK

Section: Useful Patient Resources