Cervical cancer usually develops over a number of years, often with no symptoms. It can be prevented, however, through screening and early detection; smear tests are recommended for women between ages 20 and 70 as a means of detecting cells that may develop into cancer.
Cervical cancer 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.
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 abnormal 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.
Abnormal changes in cervical cells are referred to as dysplasia; this is not cancer but could develop into cancer if not treated.
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.
Cervical cancer is caused by certain types of the human papilloma virus (HPV). HPV is a common sexually transmitted viral infection affecting an estimated 80% of sexually active women at some point in their lives. Most HPV infections clear by themselves but some high risk types can cause cell changes on the cervix that may lead to cervical cancer 10 to 20 years after infection.
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.
Factors that can increase the risk of developing cervical cancer include:
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 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.
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 or painful legs
- Lower back pain.
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 (with or without a biopsy) or cone biopsy.
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.
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 of cervical tissue is performed at the same time as the colposcopy. This involves the removal of a small piece of tissue (about the size of a match head) from the cervix. The biopsy results will take a few days to become available.
If the cervical biopsy shows abnormal cells on the surface of the cervix, a cone biopsy may be recommended. This involves the removal of a cone shaped piece of tissue from the cervix while 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.
If a diagnosis of cervical cancer is made, other tests will be performed to determine if the cancer has spread. These tests may include:
- Examinations of the bladder and bowel under an anaesthetic (cystoscopy and proctosigmoidoscopy)
- Ultrasound scan
- CT (Computed Tomography) scan
- MRI (Magnetic Resonance Imaging) scan
- PET (Positron emission tomography) scan
- Bone scan.
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:
Abnormal cells are found in the first layer of cells lining the cervix.
The cancer is found only in the tissues of the cervix.
The cancer has spread beyond the cervix to the vaginea and tissues next to the cervix.
The cancer has spread throughout the pelvic area. It may involve the lower portion of the vagina, the ureters and surrounding lymph nodes.
The cancer has spread beyond the pelvic area to other parts of the body.
Treatment of cervical cancer depends on extent of the cancer, the stage of the disease and the woman’s age and general health. It may include some form of surgical intervention, chemotherapy, radiotherapy, or a combination of these treatments.
TREATMENTS SUITABLE FOR CIS OR VERY EARLY CERVICAL CANCERS
Some very early cancers may be treated during a cone biopsy procedure. If it can be confirmed that all the cancer cells have been removed, then no futher treatment may be required.
Large loop excision of the transformation zone (LLETZ)
An electrical current is passed through a wire loop to remove abnormal cervical cells. It is a common procedure and can easily be performed using local anaesthetic.
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.
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
This is the surgical removal of the cervix, leaving the uterus behind. This treatment may be offered in cases of early stage cervical cancer where the woman is young and wishes to have children.
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. 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.
Removal of the fallopian tubes and ovaries (bilateral salpingo-oophorectomy) may be recommended for some women in addition to a hysterectomy. 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.
ADDITIONAL 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.
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 4-6 weeks.
Also called brachytherapy, this treatment involves the insertion of radioactive applicators into the cervix and vagina for a short period of time. The procedure is performed under a general anaesthetic. The aim is to position the applicators as close to the cancer as possbile in order to destroy the cancer cells.
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 can affect the ovaries and their ability to produce hormones. This may lead to menopausal symptoms and infertility.
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.
Because cervical cancer usually develops slowly and has no symptoms in the early stages, regular cervical smears to detect early cell changes are recommended for all women aged 20 to 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.
Abnormal changes in cervical cells are referred to as dysplasia. These are not cancers but could develop into cancer if not treated. Dysplasias are categorised as:
- Low grade squamous intraepithelial lesions (LSIL) - minor changes that normally resolve within 12 months, and
- High-grade squamous intraepithelial lesions (HSIL) - more serious changes that require further investigation and, sometimes, treatment.
These changes may also be called cervical intraepithelial neoplasia (CIN), and graded I (mild), II (moderate) or III (severe). Sometimes the term "carcinoma in situ" is used to describe CIN III.
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 programme 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. The National Cervical Screening Programme is available to all women in New Zealand aged 20 to 70 years.
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 females aged 9 to 45 years, and males aged 9 to 26 years. The vaccine is offered free as part of the New Zealand Immunisation Schedule to girls at 12 years of age (Year 8 at school). For maximum protection the full three-dose course should be taken.
The National Cervical Screening Programme can be contacted as follows:
Phone: 0800 729 729
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
Phone: (04) 494 7270
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.
Or 0800 800 426 (outside Auckland)
The New Zealand HPV Project (2012) HPV Vaccine. sexually Transmitted Infection Education Foundation Inc. www.hpv.org.nz/patient/hpv_vaccine.htm
Cancer Society of New Zealand (2010) Cervical cancer. Information Sheet. 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.
Immunisation Advisory Centre (2013). New Zealand Human Papillomavirus (HPV) immunisation programme (Pamphlet). New Zealand Ministry of Health.
Ministry of Health (2005) Cervical Screening in New Zealand: A brief statistical review of the first decade. Wellington: National Cervical Screening Programme
Last Updated – May 2013