Cervical Cancer
Cervical cancer usually develops slowly, often taking up to ten years to develop. It most commonly occurs in women over 35 years of age. It rarely occurs before the age of 25 years.
In New Zealand about 200 women are diagnosed with cervical cancer each year and approximately 70 women die from the disease. Cervical cancer rates are higher in Maori and Pacific Island women than in other ethnic groups.
Cervical (Pap tests) recommended for women between ages 20 and 70 as means of detecting cells that may develop into cancer. Usually, cervical smears are taken every three years unless a previous smear has indicated presence of abnormal cells, in which case the smear is performed more frequently.
The cervix is the lower part of the uterus (womb). It is approximately 2.5cm long and forms a canal to the vagina, which in turn leads to the outside of the body. The cervix produces some of the mucous that helps lubricate the vagina. The type of mucous it produces changes during fertile periods to facilitate the progress of sperm towards the fallopian tubes. During pregnancy the cervix remains tightly closed to help protect and retain the developing baby. During labour the cervix effaces (thins out) and dilates (opens up) to enable the birth of the baby.
Diagram courtesy of the Cancer Council Victoria
The cervix is made up of different types of microscopic cells. The upper part of the cervix is lined with the same type of cells that line the uterus, while the lower part of the cervix is lined with the same type of cells that line the vagina. The point where these two types of cells merge - the transformation zone, is where most instances of cervical cancer originate.
Individual cells have a limited lifespan and divide to produce new cells when required by the body. Sometimes this process is disturbed and cells divide when new cells aren’t required, or abnormal cells may develop. This overgrowth of cells can eventually lead to a malignant (cancerous) tumour forming. Some of these abnormal cells can break off and travel through the lymphatic or circulatory systems to distant parts of the body in a process called metastasis. Once there, they continue to grow and form ‘secondary’ cancers.
The two main types of cervical cancer are:
Squamous cell carcinoma: This is the most common form occurring in up to 90% of cases of cervical cancer. It begins in the skin-like cells of the cervix (squamous cells).
Adenocarcinoma: This form occurs in approximately 10% of cases of cervical cancer and is more difficult to diagnose. It begins in the glandular cells of the cervix.
It is thought that the main cause of cervical cancer is the human papilloma virus (HPV). HPV is the most common sexually transmitted infection and it is estimated that up to 75% of sexually active adults will be infected with HPV at some stage in their life.
There are more than 100 types of HPV infections, but only about 40 of these are linked to cervical cancer. While infection with HPV can cause conditions such as genital warts, it often causes no symptoms. Many women are therefore unaware they have contracted the virus.
Most infections are cleared from body within one two years. However long-term infection with HPV in cells cervix. Over many years, these changes can lead to the development of cervical cancer.
Other factors that can increase the risk of developing cervical cancer include:
Sexual activity
Cervical cancer is very rare in women who have never had sexual intercourse. Any woman who has been sexually active is at risk of developing cervical cancer. Women who began having sexual intercourse as adolescents appear to be at greater risk of developing cervical cancer. Women who have had multiple sexual partners (and those whose partners have had multiple sexual partners) also appear to be at greater risk of developing cervical cancer.
Smoking
Smoking increases a woman’s risk of developing cervical cancer. The risk appears to increase with the number of cigarettes smoked per day and the number of years of smoking.
Diethylstilbestrol (DES)
Daughters of women who were given the drug DES during pregnancy to prevent miscarriage are at increased risk of developing cervical cancer. This drug was used until around 1970.
Other factors that may increase the risk of developing cervical cancer include the use of oral contraceptives and having a weakened immune system.
During the early stages of cervical cancer there are often no symptoms at all but the most common symptom experienced is abnormal vaginal bleeding. This bleeding may occur between periods, following sexual intercourse or after the menopause. Menstrual bleeding may also be heavier.
Other symptoms that may occur include:
- Unusual vaginal discharge
- Pain in the pelvic area
- Excessive tiredness
- Swollen legs
- Backache.
(Return to top)
A number of different tests are used to diagnose cervical cancer. The first step is a pelvic examination, which may be performed by a general practitioner or gynaecologist. Once the results from this test are available, other tests performed by a gynaecologist may include a colposcopy, biopsy or cone biopsy.
Pelvic examination
This examination generally involves the doctor undertaking a visual inspection that includes the taking of a cervical smear and a bimanual examination. For the cervical smear a speculum (instrument to hold the vaginal walls apart) is gently inserted into the vagina and the doctor visually inspects the cervix. A small spatula or brush-like device is then used to gently scrape some of the cells from the surface of the cervix. These cells are placed on a glass slide and sent to a laboratory for testing. The bimanual exam involves the doctor inserting two fingers into the vagina and with the other hand on the lower abdomen trying to get an appreciation of the size and shape of the ovaries and uterus, and any abnormalities.
Colposcopy
A colposcopy is a procedure that enables the specialist to examine the cervix with the aid of a special instrument called a colposcope. A colposcope looks similar to a pair of binoculars on a stand and it magnifies the surface of the cervix. The procedure is similar to a cervical smear in that a speculum is used to hold the walls of the vagina apart. The specialist applies a vinegar-like solution to the cervix, which turns any areas of abnormal tissue white. If the doctor observes any suspicious areas of tissue during this procedure, a biopsy may be taken.
Punch biopsy
If required, this test is performed at the same time as the colposcopy. The doctor removes a small piece of tissue (about the size of a match head) from the cervix using a special punch instrument. Some discomfort similar to menstrual cramps may be felt at the time the biopsy is taken. There may be a small amount of bleeding following this procedure and sanitary pads should be used rather than tampons during this time. The doctor may also recommend abstinence from sexual intercourse for a specified time period to allow the cervix to heal. The biopsy results will take a few days to become available.
Cone biopsy
This test involves the removal of a cone shaped piece of tissue from the cervix. When there are only small amounts of abnormal tissue present, this may also be a treatment method. It can be performed under local or general anaesthetic. The tissue that is removed will be sent to a laboratory for analysis and to determine if all abnormal tissue was removed. The results will take approximately one week to become available.
For a few days after the procedure some cramp-like pain may be felt and there may also be some bleeding or discharge. Once again, sanitary pads should be used rather than tampons. Sanitary pads should also be used if the next period occurs less than a month after the cone biopsy. It is usually recommended that active sports and sexual intercourse are avoided for four to six weeks after a cone biopsy to prevent further injury to the healing tissue.
Possible complications following a cone biopsy include; severe bleeding, incomplete removal of the abnormal tissue, infection and weakening or scarring of the cervix.
If a diagnosis of cervical cancer is made, other tests will be performed to determine if the cancer has spread. These tests may include:
- IVP (intravenous pyelogram) - a special test of the kidneys, bladder and ureters (the tubes connecting the kidneys to the bladder)
- Ultrasound scan
- CT (Computed Tomography) scan
- MRI (Magnetic Resonance Imaging) scan
- Bone scan.
(Return to top)
Stages of Cervical Cancer
All cancers are given a ‘stage’. The stage indicates the size of the tumour and the extent of its spread throughout the body. Cervical cancers may be given the following stages:
Stage 0:
Cancer cells are found in the lining of the cervix but they have not grown into deeper tissues. This is not invasive cancer and may also be called carcinoma in situ (CIS).
Stage 1:
The cancer has spread into the connective tissue of the cervix but is confined to the uterus.
Stage 2:
The cancer has spread from the cervix but is confined to the pelvic region.
Stage 3:
The cancer has spread throughout the pelvic area. It may involve the lower portion of the vagina, the ureters and surrounding lymph nodes.
Stage 4:
The cancer has spread to other parts of the body.
Treatment of cervical cancer depends on the location and size of the tumour, the stage of the disease and the woman’s age and general health. It may include some form of surgical intervention, chemotherapy or radiotherapy.
TREATMENTS SUITABLE FOR CIS OR VERY EARLY CERVICAL CANCERS
Cone biopsy
This may be considered as a treatment option if the tumour is less than 3mm in depth, there is no spread to surrounding lymph nodes or tissues and there is no sign of any abnormal tissue at the edges of the removed tissue. Cone biopsy provides an opportunity for younger women to preserve their fertility.
Loop electrosurgical excision procedure (LEEP)
An electrical current is passed through a wire loop instead of using a scalpel to remove abnormal tissue. It is a common procedure and can easily be performed using local anaesthetic. It is also known as a LLETZ procedure (Large Loop Excision of the Transformation Zone).
Laser surgery
Laser (a narrow beam of intense light) can be used like a knife to remove a small part of the cervix, or more commonly, to destroy any abnormal tissue. The light from the laser is converted to heat, and it is this that destroys the tissue. Laser treatment can be painful and usually requires general anaesthetic.
Cryosurgery
In cryosurgery an instrument (called a cryoprobe) is cooled using carbon dioxide and then applied to the affected area. This freezes and destroys the abnormal cells. A watery vaginal discharge can be expected for a few weeks following this procedure while the treated tissue sloughs off.
SURGICAL TREATMENT OF CERVICAL CANCER
Hysterectomy
Hysterectomy may be recommended if the cancer hasn’t spread beyond the pelvis. There are two main types of hysterectomy that may be recommended depending on the extent of the cancer of the tumour. In a total hysterectomy, the uterus and cervix are removed. A radical hysterectomy is a more extensive operation, in which the uterus, cervix, ligaments supporting the uterus and the upper part of the vagina are all removed.
Sometimes, the pelvic lymph nodes near the uterus may also be removed and examined to determine if the cancer has spread beyond the cervix and uterus. This is more likely to be performed during a radical hysterectomy.
Recovery time in hospital will vary depending on the route used to perform the hysterectomy (abdominal or vaginal) and the extent of surgery. Up to a week in hospital may be required if a radical hysterectomy is performed.
Bilateral salpingo-oophorectomy
Removal of the fallopian tubes and ovaries (in addition to a hysterectomy) may be recommended for some women. If this is performed on women who are pre-menopausal, they will experience the sudden onset of menopausal symptoms. This is termed surgical menopause and occurs because of the removal of the ovaries, which are the body’s main producers of oestrogen. Treatment of oestrogen deficiency will often be required thereafter, to prevent conditions such as osteoporosis from developing.
NON-SURGICAL TREATMENT OF CERVICAL CANCER
Most often, treatment for cervical cancer involves a combination of surgery and radiotherapy. Sometimes chemotherapy is also used. An oncologist (cancer specialist) will be involved in deciding which treatments are most appropriate for the individual woman. There are two different types of radiotherapy – external and internal.
Radiotherapy
External radiotherapy:
This treatment involves the use of a large machine that directs a special type of x-ray to the affected area. The aim of the treatment is to kill cancer cells and shrink tumours. For women with cervical cancer this usually involves attending the hospital as an outpatient five days a week for a period of 5-6 weeks.
Internal radiotherapy:
Also called brachytherapy, this treatment involves the insertion of a radioactive implant into the body. A general anaesthetic is usually given to enable the insertion of the implant into the cervix. The implant is usually left in place for 72 hours. Since the implants are radioactive, the woman is confined to her room while they are in place. Internal radiotherapy destroys less of the healthy tissue around the tumour and has fewer side effects than external radiotherapy.
Side effects of radiotherapy:
As well as destroying the cancer tissue, radiotherapy also destroys healthy tissue near the area being treated. Common side effects include: fatigue, diarrhoea, vomiting, nausea, loss of appetite and pain when passing urine due to bladder irritation. External radiotherapy can cause skin irritation and the skin can appear sunburned for some time. Radiotherapy for cervical cancer affects the ovaries and their ability to produce hormones. This may lead to menopausal symptoms and infertility.
Chemotherapy
This is usually used if it is suspected or confirmed that the cancer has spread to other areas of the body. Chemotherapy medications can be given either by tablets or as injections into the bloodstream. Chemotherapy is usually given in cycles; with a period of treatment followed by a period of recovery, before beginning the cycle again. The medications aim to destroy any cancer cells that may be circulating in the body but they can also affect healthy tissue. Side effects vary depending on the medications used but common side effects include nausea, vomiting, hair loss, fatigue, alterations to the menstrual cycle and infertility.
After the diagnosis and treatment of cervical cancer, regular follow-up visits with healthcare professionals will be scheduled. These visits will usually involve seeing the gynaecologist and oncologist. Initially the visits will be frequent (approximately 3 monthly), but if all remains well they will gradually decrease in frequency. The visits will involve a range of monitoring procedures such as physical examinations, imaging (ultrasound scans/x-rays), blood tests and biopsies.
Cervical Screening
Because cervical cancer usually develops slowly and has no symptoms in the early stages it makes sense to have regular cervical smears to detect early changes. (Pap tests).
Cervical smears are recommended for all women between the ages of 20 and 70 who have ever been sexually active. While cervical cancer can develop in women who have never had sexual intercourse, it is very rare. Usually, cervical smears are taken every three years unless a previous smear has indicated the presence of abnormal cells, in which case the smear is performed more frequently.
When examining the cervical smear the doctor looks for abnormal cells that, if left untreated may eventually develop into cancer. While abnormal cells are occasionally not detected, if the smear is repeated at the recommended time, it is likely that on the next examination any abnormal cells will be detected.
There is a wide range of possible results following a cervical smear, most of which do not indicate the possible presence of cancer. In the past those with mildly abnormal cells (CIN1) were advised to have a repeat smear in 6 months. Nowadays it is common practice to recommend colposcopy to rule out more sinister disease. If moderate to severe cell changes (CIN2 and CIN3) are present, a colposcopy would also be the next step.
For women who have had a hysterectomy and previously had an abnormal smear, it is recommended that they continue to have smears. If their cervix has been removed the test will be a ‘vault smear’. Women who have had a hysterectomy and not previously had an abnormal smear usually do not need further smears. The doctor will be able to advise if it is necessary to continue with this testing.
In 1990 the government set up the National Cervical Screening Programme. The goal of this organisation is to reduce the incidence and mortality of cervical cancer in New Zealand by the early detection and treatment of abnormal cell changes. Results of cervical smears are confidentially kept on the register and reminders are sent out if a smear is missed.
HPV Vaccine
A vaccine against HPV is available in New Zealand. It has been formulated to prevent the four most common HPV infections that lead to cervical cancer. The target groups for vaccination are girls aged 9 to 26 years, and boys aged 9 to 15 years. The vaccine is given in a three-dose course over six months. It is thought to give protection for at least five years.
The National Cervical Screening Programme can be contacted as follows:
The Cancer Society of New Zealand is able to supply further information, support and resources for women with cervical cancer and their families. There are branches throughout New Zealand and contact details for the branches are available in the local telephone directory. Contact details for the national office are as follows:
Cancer Society of New Zealand
National Office
PO Box 10847
Wellington
Phone: (04) 494 7270
Fax: (04) 494 7271
Website: www.cancernz.org.nz
The Cancer Society also provides an information service that is staffed by specialist cancer nurses. They have an extensive library of resource books about all types of cancer that can be lent out.
Phone 308 0162 (within Auckland)
Or 0800 800 426 (outside Auckland)
E-mail: information@akcansoc.org.nz
Australia and New Zealand HPV Project (2002) Cervical pap smears and human papilloma virus infection (HPV). Auckland: Viral Sexually Transmitted Infection Education Foundation Ltd
http://www.hpv.org.nz/pdf/cervical_smears_hpv.pdf
Cancer Society of New Zealand (2001) Cervical cancer. Wellington: Cancer Society of New Zealand Inc
Cherath, L., Alic, M., Odle, T.G. (2006) Cervical Cancer. The Gale Encyclopaedia of Medicine. Third Edition. Jacqueline L. Longe, Editor. Farmington Mills, MI. Thompson Gale.
Everybody (2001) Cone biopsy. Auckland: MediMedia (NZ)
http://www.everybody.co.nz/page-036ff17d-8470-4c80-b9b2-13d98de00bb3.aspx
Ministry of Health (2005) Cervical Screening in New Zealand: A brief statistical review of the first decade. Wellington: National Cervical Screening Programme
Last Updated – 15/05/07