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Cancer of the cervix is one of the most common cancers that affects not only the woman’s reproductive system, but the woman as a whole.
A variety of strains of the human papilloma virus (HPV), a sexually transmitted infection (STI) – we don’t say STD much anymore – are the cause of the majority of cases of cervical cancer.
When exposed to HPV, the immune system response in most women keeps the virus under raps. In a small group of women, however, the virus survives for years, then eventually converts some cells on the surface of the cervix into cancer cells. 50% of cases of cervical cancer occur in women between the ages of 35 and 55.
Thanks largely to PAP test screening, the death rate from this cancer has diminished significantly over the last 40 years. But it still claims far too many victims, underscoring the need for women to get their PAP test done. It is still our best means of early detection so that we can lick this thing when we find any hint of cancer.
WHAT ARE THE SIGNS AND SYMPTOMS?
Early cervical cancer generally produces no signs or symptoms. As the cancer progresses, some signals may appear:
• Bleeding from the vagina after intercourse, called post-coital bleeding. Bleeding may also occur between periods or after menopause when, of course, it shouldn’t.
• Watery, bloody vaginal discharge that may be heavy and have a foul odor.
• Pelvic pain (below the waist) or pain during intercourse (dyspareunia).
WHAT ARE THE RISK FACTORS?
Here are some factors which increase your risk of cervical cancer.
Many sexual partners. The greater the number of partners you’ve had, and the greater the number of partners that they’ve had, the greater your chances of being infected with the HPV.
Early sexual activity. Having your first sexual encounter before age 18 increases your risk for getting HPV. Girls, listen to your parents! Immature cells seem to be more susceptible to the pre-cancerous changes that HPV can cause.
Other STI’S. Having Chlamydia, gonorrhea, syphilis or HIV/AIDS means you have a greater chance of being exposed to HPV.
Cigarette smoking. How cigarette smoking contributes to the problem isn’t known for sure, but tobacco use increases the risk of precancerous changes as well as cancer of the cervix.
A weakened immune system. Most women with HPV never develop cervical cancer. However, if there is a co-existing condition that weakens the immune system, cervical cancer is more likely to develop.
SCREENING AND DIAGNOSIS
Almost everyone, men included, have heard of the PAP smear or a PAP test. The doctor, or nurse uses a brush or Q-tip-like swab to remove cells from the cervix, smears them onto a glass slide and sends the slide to the lab where a cytotechnologist, then a pathologist, examines it. The latter then reports the findings.
A newer approach to the PAP screening uses a liquid to transfer the sample of cells to the laboratory. The cells are collected the same way, but the brush is rinsed in a special liquid, which preserves the cells for examination later. At the lab, a microscopic slide that’s clearer and more easily interpreted than the traditional method, is prepared.
A PAP test allows for the detection of abnormal cells. This is the precancerous stage, when the abnormal cells are only in the outer layer of the cervix and have not invaded deeper tissues. Left untreated, the abnormal cells may become cancer cells which may spread in various stages into the cervix, the upper vagina, the pelvic areas and to other body parts.
Cancer or precancerous conditions that are caught at the pre-invasive stage are rarely life-threatening and usually can be treated on an out-patient basis.
HPV DNA TEST
This test may be used to see whether you are infected with any of the 13 types of HPV (unlucky 13) that are most likely to lead to cancer of the cervix. It also involves collecting cells from the cervix to test at the lab. It can detect high-risk strains of HPV in cell DNA before changes to the cervical cells can be seen.
This HPV DNA testing is not a substitute for regular PAP screening, and is not used to screen women younger than 30 with normal Pap smear results. Most HPV infections in women of this age group clear up on their own and are not associated with cervical cancer.
WHAT ABOUT TREATMENT?
This is when only the outer layer of the lining of the cervix is involved. Treatments include:
• Conization. A scalpel is used to remove a cone-shaped piece of abnormal cervical tissue.
• Laser surgery.
• Loop electrosurgical excision procedures (LEEP). A wire loop conducts an electrical current; it cuts like a surgeon’s knife and removes cells from the mouth of the cervix.
• Cryosurgery. Cancerous and precancerous cells are frozen and killed.
• Hysterectomy. This removes cancerous and precancerous areas, the cervix and the uterus.
All women with pre-invasive cervical cancer can be cured with appropriate treatment.
When confined to the cervix in the invasive stage, the five-year survival rate for cancer is over 90%.
• Hysterectomy. Surgery is usually recommended for younger women because one of both ovaries can be preserved for estrogen production to maintain bone strength and avoid osteoporosis. A SIMPLE HYSTERECTOMY – removing the cancer, the cervix and the uterus – is usually the option when there is an invasion of less than 3 millimeters into the cervix. A RADICAL HYSTERECTOMY – cervix, uterus, part of the vagina and lymph nodes (glands) in the area – is the standard surgical treatment when there’s an invasion of greater than 3mm into the cervix, and no evidence of tumor on the pelvic walls.
• Radical trachelectomy. Women with early-stage cervical cancer may preserve their fertility with this surgical procedure. In this, the cervix and lower part of the uterus are removed. Enough of the latter is left so that a pregnancy can be carried. Pelvic lymph nodes are also removed to determine whether cancer has spread.
• Radiation. High-energy rays shrink tumors by killing cancer cells. Cancer cells are rendered unable to reproduce. Premenopausal women will become menopausal because the radiation destroys their ovarian function.
• Chemotherapy. Drugs enhance the effects of radiation in treating cancer.
Some women with early-stage cancer are treated with simple hysterectomy or radical trachelectomy alone. Women with more advanced cancer and those with high risk of recurrence are given radical hysterectomy, combined radiation and chemotherapy, or a combination of these modalities.
CAN I PREVENT CERVICAL CANCER?
Yes. HPV transmission is not prevented by condom use because the virus can be transmitted by skin-to-skin contact with any infected part of the body. However condoms protect against other STI’S that could weaken your immune system.
The best ways to prevent cancer of the cervix are to:
• Delay fist intercourse
• Have fewer sexual partners
• Don’t smoke
PAP TEST GUIDELINES
By now you know the PAP test is crucial. Current guidelines suggest.
• An initial PAP test three years after you begin having sexual intercourse, or at age 21, whichever comes first.
• From age 21 to 29, a regular test each year or a liquid based test every two years.
• From age 30 to 69. – If you have had 3 normal test in a row – a regular PAP test every two years or a liquid based test every three years.
From age 70 onwards, you may stop having tests if you’ve had three or more normal ones in a row and no abnormal results in the last 10 years.
Space does not permit me to discuss how we stage cervical cancer. Drop me a note or ask any question, and I’ll tell you, or maybe we’ll talk about cervical cancer from another angle some other time.
See you next week.
Dr. Emanuel, based in the Commonwealth of Dominica, has been an educator of medical professionals, in training and the public, for over 20 years.