Cervical cancer

ABOUT THIS CONDITION

Cervical cancer is the occurrence of abnormal growth of the cells of the cervix, the lower end of the uterus that connects the uterus to the vagina. This cancer cell growth typically starts in the outer layer called the squamous cells. Less commonly, it starts in gland cells of the cervix. There are significant steps you can take to reduce your risk of cervical cancer, including receiving HPV (human papillomavirus) vaccines and early screening tests, such as the smear (Pap) and HPV tests.

Understanding cervical cancer

What are the types of cervical cancer ?

When cells in the cervix begin to grow in ways that are not normal, it is called cervical intraepithelial neoplasia (CIN). CIN is not cancer, but it can lead to cancer if not treated. Once cancer forms, there are 3 possible types:

  • Squamous cell carcinoma. This starts in the thin, flat cells on the surface of the cervix. This is by far the most common form of cervical cancer.

  • Adenocarcinoma. This starts in gland cells of the cervix.

  • Mixed carcinoma or adenosquamous carcinoma. This is cancer in both types of cells.
  • Rare types (melanoma, sarcoma, lymphoma, neuroendocrine, gastric type)

 

What causes cervical cancer?

In the vast majority of cases (> 99%), it is the result of a chronic, active infection with high-risk types of human papilloma virus (HPV). HPV infection is strongly linked to cervical cancer. But it's important to know that most women with HPV don’t develop cervical cancer.

Other risk factors include:

  • Sex at a young age or with multiple partners.

  • Smoking.

  • Infection with HIV, or a weak immune system 

  • Long-term use of birth control pills

  • Three or more full-term pregnancies

  • First full-term pregnancy before age 17

  • No regular Pap tests

  • Personal or family history of cervical cancer

  • Past chlamydia infection

  • Your mother took the medicine DES (diethylstilbestrol) whilst pregnant with you.

 

Can cervical cancer be prevented?

Cervical cancer most often starts with pre-cancer cell changes. You can take steps to help prevent these changes that lead to cervical cancer. To help lower your risk:

 

What are the symptoms of cervical cancer?

Early cervical cancer doesn’t usually have symptoms. They are typically found during regular screening exams, and cure rates are very high for these people. Once the cancer has invaded deeper into the cervix or nearby organs, you might have symptoms. These may include:

  • Vaginal bleeding or spotting, especially after vaginal intercourse, bleeding or spotting in between menstrual periods, bleeding or spotting after menopause, or menstrual periods that are heavier or last longer than usual
  • Pelvic pain
  • Pain during intercourse
  • Vaginal discharge that can be watery, bloody, or have a foul odour

Diagnosing cervical cancer

Cervical cancer can be diagnosed with a PAP test or, directly, by taking biopsies, usually after colposcopy. Other times, it is identified after a conisation (LETTZ) which is performed for the treatment of pre-cancerous lesions (CIN). 

 

What should I do if I am diagnosed with cervical cancer?

If the cervical biopsy shows cervical cancer, the next step for the patient is to visit a Certified Gynaecological Oncologist. Seeking specialist care is ctrucial, as Gynaecological Oncologists have the knowledge, training, and experience to provide the best cervical cancer care. 

 

Will I need other tests ?

After a diagnosis of cervical cancer, you’ll likely need other tests in order to determine the stage of the cancer. The stage is how much and how far the cancer has spread in your body. It’s one of the most important things to know when deciding how to treat the cancer. The following exams may be used to ascertain the stage of the diasease:

  • Examination under anaesthesia
  • Magnetic Resonance Imaging (MRI) of the lower abdomen with intravenous contrast agent
  • PET/CT or alternatively chest CT and upper abdomen CT or MRI with intravenous contrast agent
  • Rarely, cystoscopy and/ or orthoscopy,

Treating cervical cancer

Cervical cancer treatment can include surgery, radiation, chemotherapy or a combination of treatments. Your treatment plan will depend on how deeply the tumour has penetrated the tissue, if lymph nodes are involved, and if cancer has spread to other parts of the body. This is called staging. Your age, general health, and your desire to have children in the future also come into play for your treatment plan. The goal of treatment may be to cure you, control the cancer, or to help ease problems caused by cancer.

 

Surgical management 

In the early stages of the disease, surgical treatment is possible. The extend of the disease is determined by the stage and other histological parameters as well as the desire for fertility preservation. The classic surgical treatment of cervical cancer is the performance of a radical hysterectomy, which involves removing the uterus, cervix, tissues surrounding the uterus (parametria) and the upper part of the vagina. However, for very early stages (IA1-IB1), the conisation (IA1 or IA2) or total hysterectomy (IA1-IB1) are acceptable and safe options. The surgical removal of the ovaries is not necessary in cervical cancer and especially in the squamous type, if a woman wants to avoid early menopause.

 

Fertility-sparing procedures

For women with early-stage disease (IA1-IB1) who wish to preserve their fertility, the conisation or trachelectomy (simple or radical) are associated with excellent fertility and oncological outcomes.

 

Role of lymphadenectomy

Depending upon the size of the tumour and the depth of cervical filtration, the risk of lymph node metastases varies. For very early disease stage (IA1), without the presence of lymphovascular invasions (LVI), the risk of lymph node involvement is very low, and the removal of the lymph nodes can be omitted. For stages IA2 and above, the systematic removal of regional (pelvic) lymph nodes is recommended.

 

How is surgery performed on patients with cervical cancer?

There is evidence to suggest that minimal invasive surgery approach for radical hysterectomy for cervical cancer is associated with significantly worse oncological outcomes than open surgery. In view of these findings, the Royal College of Obstetricians & Gynaecologists (RCOG) and the European Society of Gynaecological Oncology (ESGO) consider the open surgery (laparotomy) as the 'gold standard' approach for radical hysterectomy for cervical cancer. On the other hand, when total hysterectomy is sufficient to treat the disease, minimally invasive surgeryis seemingly advantageous under certain conditions.  

 

Role of exenteration

Locally advanced disease is usually treated with combined chemo-radiotherapy. However, for highly selected patients  who met specific criteria and when there is contraindication for radiotherapy (e.g. fistulas), an exenterative procedure may be a tratment option.

Excellence in surgical care

Dr. Tranoulis is highly experienced in the treatment of gynaecological cancers and a recognised leader in his field. International studies have demostrated that surgeons performing higher volumes of particular procedures can often offer patients better outcomes, such as shorter hospital stays and fewer complications. Studies also confirm that cervical cancer patients initially treated by Gynaecological Oncologists have improved oncological outcomes compared to those treated by general gynaecologists or general surgeons.

Depending on the location and stage of your cancer, Dr Tranoulis may recommend:

Surveillance

Once you’re finished with treatment, you’ll enter a period of surveillance to make sure the cancer doesn’t return, and if it does, to catch it early. Dr Tranoulis will create an individualised follow-up plan for you which includes:

  • Periodic clinical examination, including gynecological examination (every 3-6 months)
  • Annual PAP test
  • Periodic screening tests. The available options include computed tomography or magnetic resonance imaging and PET/CT, so the relevant decisions are made based on the doctor’s judgment and the symptoms that the patient may have.

Recurrence

When cancer comes back after treatment, it’s called recurrence. Cancer can recur anywhere in your body, including your pelvis or abdominal cavity, or distant areas such as your lungs, liver, or bone. The symptoms of recurrence may include:

  • Vaginal bleeding
  • Pelvic or abdominal pain
  • Nausea or vomiting
  • Changes in bowel or bladder habits

It’s important to communicate any of these symptoms of recurrence to your Gynaecological Oncologist.

 

Treatment of recurrence

Treatment depends on what previous treatment you had and the site and extent of the disease. Your individualized care plan can include surgery (exenteration), radiation, and chemotherapy.

Coping with fear

Being told you have cervical cancer can be scary, and you may have many questions. We are here to help you. Learning about your cancer and about the treatment options available to you can make you feel less afraid.