Cervical cancer

Cervical cancer usually develops over many years, often with no symptoms. It can be prevented, however, through screening and early detection.

In New Zealand about 160 women are diagnosed with cervical cancer each year and approximately 50 women die from the disease. Smear tests are recommended for women starting from age 25 years as a means of detecting abnormal cervical cells that may develop into cancer.

Causes

Almost all cervical cancer is linked to certain types of the human papilloma virus (HPV). HPV is a common sexually transmitted viral infection in females and males affecting an estimated 80% of sexually active adults at some point in their lives.

Most HPV infections in women clear by themselves but some variations of the infection can cause abnormal cell changes on the cervix that may lead to cervical cancer 10 years or more after infection.

The two main types of cervical cancer are:

• Squamous cell carcinoma - This is the most common form occurring in up to 80% of cases of cervical cancer. It begins in the skin-like cells of the cervix (squamous cells).
• Adenocarcinoma - This form occurs in approximately 15% of cases of cervical cancer and is more difficult to diagnose. It begins in the glandular cells of the cervix.

Factors that can increase the risk of developing cervical cancer include:

• Sexual activity - Any woman who has been sexually active is at risk of developing cervical cancer. Cervical cancer is rare in women who have never had sexual intercourse.
• Genetics - Due to certain gene mutations, some women are more likely to develop cervical cancer than others.
• Smoking - Smoking increases a woman’s risk of developing many types of cancer, including cervical cancer. The risk appears to increase with the number of cigarettes smoked per day and the number of years of smoking.
• Weakened immune system.

Symptoms

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 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.

Diagnosis

Several different tests are used to diagnose cervical cancer.

Pelvic examination

This examination generally involves a GP or gynaecologist undertaking a visual inspection, cervical smear and 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. Cells are scraped from the surface of the cervix 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 a gynaecologist to examine the cervix with the aid of a special instrument called a colposcope. A speculum is used to hold the walls of the vagina apart so that the colposcope can view the surface of the cervix. If the doctor observes any suspicious areas of tissue during this procedure a biopsy is done, which involves removing a small piece of cervical tissue – the size of a match head – and sending it to a laboratory for analysis.

Cone biopsy

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, MRI or PET scan
• Bone scan.

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: Abnormal cells are found in the first layer of cells lining the cervix.
• Stage I: The cancer is found only in the cervix.
• Stage II: The cancer has spread beyond the cervix to the upper portion of the vagina.
• Stage III: The cancer has spread throughout the pelvic area. It may involve the lower portion of the vagina, ureters, and surrounding lymph nodes.
• Stage IV: The cancer has spread to nearby organs such as the bladder or rectum, or to other parts of the body (eg: lungs, liver, bones).

Treatment

Treatment of cervical cancer depends on the 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. An oncologist (cancer specialist) will be involved to advise which treatments are most appropriate for the individual woman.

Treatments suitable for very early cervical cancers

• Cone biopsy - Some 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 further 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 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. Laser treatment can be painful and usually requires general anaesthetic.
• Cryosurgery - In cryosurgery, an instrument is cooled using liquid nitrogen and then applied to the affected area. This freezes and destroys the abnormal cells.

Surgical treatment of cervical cancer

• Trachelectomy - 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.
• Hysterectomy (total and radical) - Hysterectomy may be recommended if the cancer has not spread beyond the pelvis. 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.

Radiotherapy

There are two different types of radiotherapy (also known as radiation therapy).

• 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 4–6 weeks.
• Internal radiotherapy - Also called brachytherapy, this treatment involves the insertion of radioactive applicators into the cervix and vagina for a short period of time, ie: radiation is delivered to the cancer from inside the body. The procedure is performed under a general anaesthetic. The aim is to position the applicators as close to the cancer as possible in order to destroy the cancer cells.

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.

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 may include nausea, vomiting, hair loss, fatigue, alterations to the menstrual cycle, and infertility.

Follow-up

After the diagnosis and treatment of cervical cancer, regular follow-up visits with healthcare professionals will be scheduled, involving a range of monitoring procedures such as physical examinations, imaging (ultrasound scans/x-rays), blood tests and biopsies.

Prevention

Cervical screening

The goal of New Zealand's National Cervical Screening Programme is to reduce the incidence and mortality of cervical cancer by the early detection and treatment of abnormal cell changes. It is available to all women in New Zealand between the ages of 25 and 69 years.

It is estimated that, without cervical screening, one out of 90 women will develop cervical cancer and one in every 200 will die from it. With cervical screening, one out of 570 women will develop cervical cancer and one in 1280 will die from it.

Because cervical cancer usually develops slowly and has no symptoms in the initial stages, regular cervical smears to detect early cell changes are recommended. 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.

Results of cervical smears are confidentially kept on the register and reminders are sent out if a smear is missed.

HPV vaccine

The HPV vaccine (which involves a three-dose course) is recommended (and funded by PHARMAC) for males and females aged from 9 years to under 27 years. A school-based immunisation programme for students in year 8 is available in most areas of New Zealand. Males are included in the vaccination programme because research shows that HPV infection is shared during sexual activity and males are at risk of HPV-related cancers. For maximum protection, the full three-dose course of the HPV vaccine should be completed. The HPV vaccine is most effective if given before becoming sexually active.

Further support

For more information about cervical testing, the National Cervical Screening Programme can be contacted as follows:

National Cervical Screening Programme

Freephone: 0800 729 729
Website: www.timetoscreen.nz/cervical-screening/

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
Email: [email protected]
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 booklets, fact sheets, and audio files about all types of cancer that can be downloaded from the website.

Freephone: 0800 CANCER or 0800 226 237
Email: [email protected]

References

New Zealand HPV Project (2019). Preventing HPV cancers by vaccination: What everyone should know (PDF Information Sheet). Auckland: New Zealand HPV Project – Sexually Transmitted Infection Education Foundation. https://www.hpv.org.nz/application/files/4115/7559/0668/HPV-Vaccination-print.pdf
Cancer Society of New Zealand (2016). Cervical cancer (PDF Information Sheet). Wellington: Cancer Society of New Zealand. https://auckland-northland.cancernz.org.nz/assets/Cancer-information/Cervical-cancer/Cervical-cancer.pdf
Immunisation Advisory Centre (2020). Human papillomavirus (HPV) (PDF Pamphlet). Auckland: Immunisation Advisory Centre. https://www.immune.org.nz/sites/default/files/resources/Written%20Resources/DiseaseHpvImac20200703V01Final.pdf
Mayo Clinic (2019). Cervical cancer (Web Page). Rochester, MN: Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501 [Accessed: 15/07/20]
Ministry of Health (2014). Cervical cancer (Web Page). Wellington: Ministry of Health. https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/cervical-cancer [Date accessed: 15/07/20]
Ministry of Health (date not stated). Time to screen: Cervical screening (Web Page). Wellington: Ministry of Health. https://www.timetoscreen.nz/cervical-screening/ [Date accessed: 15/07/20]
Ministry of Health (date not stated). Time to screen: About cervical cancer (Web Page). Wellington: Ministry of Health. https://www.timetoscreen.nz/cervical-screening/why-go/about-cervical-cancer/ [Date accessed: 15/07/20]
National Screening Unit (2005). Cervical Screening in New Zealand: A brief statistical review of the first decade (PDF Report). Wellington: National Cervical Screening Programme Ministry of Health. https://www.nsu.govt.nz/system/files/resources/ncsp-statistical-review.pdf

Last Updated – July 2020

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