indiacancer.org - Cervical Cancer

	Cervical Cancer

		What is the Uterine Cervix?
		What is cancer of the Cervix?
		How does Cancer of the Cervix present?
		How is Cancer of the Cervix detected?
		What are staging and grading?
		How is Cancer of the Cervix treated?
		What are the side effects of treatment for Cancer of the Cervix?
		What is the importance of follow up?

What is the Uterine Cervix?

The uterine cervix is the entry to the uterus or the womb. The uterus is the hollow pear-shaped organ where a baby develops. The cervix is the conduit between the uterus and the birth canal or the vagina.

The cervix is roughly divided into two parts, the ectocervix and the endocervix.

The ectocervix is located towards the outside, facing the birth canal and have a cellular lining which is squamous in nature.

Squamous cells are those cells which are flat and scale-like in nature.

The endocervix is the inner part of the cervix facing the uterus or the womb and the cells are of a glandular nature.

Side view of the cut section of the Vagina with the Uterus on top.

	What is cancer of the Cervix?

The bottom part of the pear shaped Uterus in the Cervix

The bottom part of the pear shaped Uterus is the Cervix.

Carcinomas or cancers which arise in the ectocervix are usually squamous carcinomas and carcinomas which arise in the endocervical sites are adenocarcinomas. Cervical cancers usually are squamous carcinomas.

Cancer of the cervix is a common kind of cancer in women. Usually cancer of the cervix is a slow-growing disease, which develops over a period of time. Before cancer develops in its full-blown form, the tissues of the cervix undergo certain changes in which cells slowly progress from normal to abnormal to the downright malignant. As the cells go through these intermediate steps, they are said to be becoming dysplastic. A Pap smear or a Papanicolaou smear will usually find these cells. For more details about Pap smears, please check the Pap smear section.

Cancer cells start to grow and spread more deeply in the cervix and to surrounding areas as the disease progresses. The most dangerous thing about a cancer of the cervix is that very little symptomatology is associated with it.

	How does cancer of the Cervix present?

	As mentioned above, very few symptoms are associated with early cancer of the cervix. Therefore, depending upon the risk factors involved, a doctor should do a series of tests to look for it aggressively.
		The presentation may be very subtle or gross
		Bleeding after intercourse
		Unprovoked bleeding from the cervix
		Foul smelling or clear white discharge from the cervix and vagina
		An obvious mass in the cervix and vagina
		No clinically detectable lesion in the cervix, but there is a lump in the groin or in the abdomen, that is, the cancer is picked up after it has already spread (metastasized) to lymph nodes. (Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph, a clear watery fluid, which courses through out the body in transparent, thin tubes called lymph channels or lymphatics, from various organs).

	How is Cancer of the Cervix detected?

The first of the investigations is a Pap smear which is done by using a brush, a spatula or a piece of cotton to gently scrape the ectocervix in order to pick up cells for cytological examination under the microscope.

If no abnormal cells are found and if the history is very suggestive, the doctor may need to take a sample of tissue called biopsy from the cervix and look at it under the microscope to see if there are any cancer cells. The biopsy can be done on an outpatient basis in the doctor's office.

An instrument which helps the doctor to perform this investigation is called a colposcope. For more details about colposcopy, please check the glossary.

Sometimes a larger cone-shaped biopsy specimen may have to be taken. This procedure is called conization and for this the patient may need to be admitted to the hospital.

	What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome.

Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, IVU, Bone scan or chest X-ray.

The stages of carcinoma cervix are as follows:

Stage 0 or carcinoma in situ.
This is a very early cancer in which the abnormal cells are found only in the first layer of the cells lining the cervix and do not penetrate the basement membrane, which is the bottom of the first layer of the cervix.

Stage I.
Cancer is involving the cervix beyond the basement membrane but has not spread to other tissues.

Stage IA.
A very small amount of cancer that is just visible under a microscope and is found deeper in the tissues of the cervix.

Stage IB.
A larger amount of cancer is visualized in the tissues of the cervix.

Stage II.
Cancer has spread to nearby areas but is still restricted to the pelvis.

Stage IIA.
Cancer has spread beyond the cervix to the upper two-thirds of the birth canal or the vagina.

Stage IIB.
Cancer has spread to the tissues around the cervix.

Stage III.
Cancer is involving almost the entire pelvic area. Cells have spread to the lower part of the vagina and the cells may also spread to block the tubes which connect the kidneys to the urinary bladder and which are known as ureters.

Stage IV.
Cancer has disseminated to various parts of the body.

Stage IVA:
Cancer has spread either to the urinary bladder or the rectum which are organs adjacent to the cervix.

Stage IVB.
Cancer has spread to distant organs such as the lungs, bones or the brain.

Recurrent cancer of the cervix. Which has come back after primary treatment for the cervical cancer is over. Recurrent cervical cancer may come back in the cervix itself or may present in some other part of the body.

	How is Cancer of the Cervix treated?

	A lot depends on the patient's constitution, the grade of her disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an an oncosurgeon, a gynecologist and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add on. Treatment strategies. The bastions of treatment for cancer of the cervix include surgery, radiation, chemotherapy. Variations of surgeries for various types of cancers include a special type for carcinoma in situ of the cervix in which cryosurgery is used, in which a cryoprobe or a freezing instrument is used to freeze the cancer cells and kill them. Laser surgery (Light Amplification by Stimulated Emission of Radiation) is a surgery in which a narrow beam of intense light is used to kill the cancerous cells. One of the following operations may be performed to take out smaller diseases of the cervix:
		Conization, which is removal of a cone-shaped piece of tissue where the abnormality is found. It may be used to take a biopsy but it can also be used to treat early cancers of the cervix.
		An alternate to conization is performance of a loop electrosurgical excision procedure (LEEP) to remove the abnormal tissue. LEEP uses an electrical current passed through a wired loop to act as a knife.
		A laser beam can also be used like a knife to remove the tissues.
		A hysterectomy is an operation where the uterus and the cervix are taken out along with the cancer. If it is taken down from below, that is through the vagina, it is known as a vaginal hysterectomy . If the uterus is taken out by making an incision or a cut in the abdominal wall, then it is known as an abdominal hysterectomy.
		Most of the times, the ovaries and the fallopian tubes also have to be removed, and this is called bilateral salpingo-oophorectomy.
		A radical hysterectomy also known as a Wertheim's hysterectomy is an operation in which the cervix, uterus, and a vaginal cuff are removed. Lymph nodes in the posterior aspect of the abdomen behind the peritoneum are also removed.
		If cancer has spread outside the cervix and the female organs, then some surgeons may opt to remove the lower large intestine, rectum or bladder depending where the cancer has spread along with the cervix, vagina and the uterus. This is called a pelvic exenteration and is rarely ever performed these days.
		Plastic surgery to form a new artificial vagina may be included in the surgery.
	The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Radiation, especially internal radiation plays a very special role in cancer of the cervix, because there are early cancers in which either the surgical or the radiation option can both be offered. The radiation option does just as well as the surgical option. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the cervix is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. Treatment of cervical cancer during the time of pregnancy may be delayed depending on the stage of the cancer, the aggressiveness of the disease and how many months the patient has been pregnant. For stage 0 cervical cancers, treatment options may be one of the following:
		Conization.
		Loop electrosurgical excision procedure (LEEP).
		Laser surgery.
		Cryosurgery.
		Total abdominal or total vaginal hysterectomy.
	For stage I cervical cancer. Stage I A
		Total abdominal hysterectomy with bilateral salpingo-oophorectomy, but salpingo-oophorectomy may be avoided in younger woman under special circumstances.
		Conization.
		When a tumour shows greater invasion, that is, invasion greater than 3 to 5 mm into the adjacent areas of the uterus, then Wertheim's hysterectomy or a variant of the Wertheim's hysterectomy may be performed.
		Radical brachytherapy.
	For stage I B cancers
		Radical internal as well as external radiation.
		Wertheim's hysterectomy.
		Wertheim's hysterectomy followed by radiation plus chemotherapy.
		Radical radiation therapy plus radicle chemotherapy.
	For stage II cervical cancer. One of the following options may be exercised. For stage II A cancers
		Radical brachytherapy and teletherapy.
		Wertheim's hysterectomy.
		Wertheim's hysterectomy plus radiation plus chemotherapy.
		Radical radiation therapy plus chemotherapy.
	For stage II B cancers
		Radical brachytherapy plus teletherapy plus chemotherapy.
	For stage III cervical cancer. One of the following options may be entertained.
		Radical brachytherapy, and teletherapy plus chemotherapy.
	For stage IV cervical cancer, One of the following options may be entertained For stage IV A cancers
		Radical brachytherapy and teletherapy plus chemotherapy.
	For stage IV B cancers
		Palliative radiotherapy for symptoms caused by the cancer and palliative chemotherapy.
	For treatment of recurrent cervical cancer, the basic dependence is on the fact whether the tumour has come back in the pelvis or whether it has come back elsewhere.
		Radiation therapy, usually teletherapy, along with combination chemotherapy.
		Palliative chemotherapy.

	What are the side effects of treatment for Cancer of the Cervix?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are her chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

	What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.