CERVICAL CANCER.

What is cervical cancer?

Cervical cancer is a malignancy that affects the cells lining the woman’s cervix, which connects the uterus and the vagina. The cervix plays an important role in the female reproductive system for conception, maintenance of pregnancy and timely delivery.
This cancer may affect the deeper tissues of the cervix and may spread often to the lungs, liver, bladder, vagina and rectum. This is described as metastasis. It is the second most common type of cancer which occurs when the cells in a woman’s cervix change from their normal characteristics as will be observed under a microscope by a pathologist.

According to WHO, in 2018, 511000 women were diagnosed with cervical cancer worldwide and 311000 women died from the disease. Kenya losses 9 women daily and this figure translates to 3285 annually!

Causes of cervical cancer.

In cases where one is immunosuppressed (low immunity), then one is likely to develop the cancer.

Cervical cancer has a low latency period and symptoms may begin showing after 20-30 years after infection on the assumption that the majority of youth engage in sexual practices from the ages of 18-24 years. Early sexual debut remains a huge challenge(Durowade et al., 2017). Timely HPV vaccination happens to be the appropriate course of action.

Once the cell is infected,the virus moves into the cell nucleus and integrates into the hosts DNA. This will result to mutation of the DNA and the cells formed will have abnormalities that results into cancer.

Some Human Papilloma Virus (HPV) types carry a higher risk of causing cervical cancer (HR-HPV). This includes type 16 and 17 that cause 70% of cervical cancer.

NB: HPV 16 may also cause oral cancer.

HPV- (HR-HPV) spread through unprotected sexual intercourse from male partner(s) who has/ have multiple sexual partners. It’s important to note that exposed men will always be asymptomatic for this particular virus because of the sexual anatomic differentiation from that of the females.

As HPV is a sexually transmitted virus, men are crucial in the prevention of cervical cancer(Kim et al., 2018). This provides an approach in prevention strategies.

  • Mutations in their DNA  may occur or present uncontrollable growth of cells, which do not die as compared to normal cell growth that die eventually.


Symptoms may include;

  • Vaginal bleeding after and during intercourse
  • Vaginal bleeding between periods or after menopause
  • Watery heavy vaginal discharge that may be heavy and have a foul odor
  • Dyspareunia (pain during intercourse)

Testing.

As a diagnostic confirmation, testing is crucial for any type of cancer before care is initiated.

Testing may be done to confirm presence of HPV or the abnormal cellular structures and or extent of spread to other tissues.

The following are available tests.

  1. Cobas® 4800 test which approved by FDA.

It’s more sensitive (>95%) than PAP smear (<60%).

It can be done to samples collected by self as well as one collected by your gynaecologist.

Quicker results and validated for women of 25years and above.

  • Pap test.

Pap smear is the gold standard, as this is done by a qualified gynecologist and examined by a qualified pathologist.

Its the most common test used to look for early changes in cells that can lead to cervical cancer. It involves use of special brush to scrape off cells from the cervix and upper vagina. It’s a painless procedure.

The collected cells will be sent to a laboratory where a pathologist will examine under a microscope for abnormal characteristics.

  • Ultrasound exam.

A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs in the pelvis and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.

  • MRI (Magnetic Resonance Imaging).

A procedure that uses a magnet and radio waves to make a series of detailed pictures of areas inside the body, such as the pelvis. The pictures are made by a computer. This procedure is also called nuclear magnetic resonance imaging (NMRI).

  • Computerized Tomography (CT scan).

A procedure that makes a series of detailed pictures of areas inside the body, such as the pelvis, taken from different angles. The pictures are made by a computer linked to an x-ray machine. This procedure is also called computed tomography or computerized axial tomography.

  • Bone scan.

A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones with cancer and is detected by a scanner.

  • Cystoscopy.

A procedure that looks inside the bladder and urethra to check for abnormal areas. A cystoscope is inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.

  • Proctoscopy.

A procedure for looking inside the rectum and anus to check for abnormal areas, using a

proctoscope. A proctoscope is a thin, tube-like instrument with a light and a lens for viewing the inside of the rectum and anus. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.

How to prepare for testing.

For accurate results;

  • It’s advisable that one does not have sexual intercourse for 2 to 3 days before the test
  • Avoid washing away abnormal cells
  • Avoid use of tampons, birth control foams, vaginal pessaries, douches, vaginal creams or powders at least 3 days before the test

What if I’m on my periods?

The best time to schedule your Pap test is at least 5 days after the end of your menstrual period. A Pap test can be done during your menstrual period, but it is better to schedule the test to another time.

Clinical staging.

This is a determination of extent of cancer in the body.

For cancer of the cervix,once the symptoms of unknown cause of bleeding, dyspareunia and discharge of thick yellow fluid with foul smell begin showing then this is an indication of progression of the malignancy.

Staging is important in determining the type clinical care that will be prescribed. May be clinical based on the observation of the physician or pathological based on the examination of biopsies in the laboratory.

Below is a guideline based on the International Federation of Gynacology and Obstetrics (FIGO).

FIGO StageStage Description.
I The cancer cells have grown from the surface of the cervix into deeper tissues of the cervix. Cancer has not spread to nearby lymph nodes. Cancer has not spread to distant sites.
 IAThere is a very small amount of cancer, and it can be seen only under a microscope. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IA1The area of cancer can only be seen with a microscope and is less than 3 mm (about 1/8-inch) deep. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IA2The area of cancer can only be seen with a microscope and is between 3 mm and 5 mm (about 1/5-inch) deep. It not has not spread to nearby lymph nodes. It has not spread to distant sites.
 IBThis includes stage I cancer that has spread deeper than 5 mm (about 1/5 inch) but is still limited to the cervix. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IB1The cancer is deeper than 5 mm (about 1/5-inch) but not more than 2 cm (about 4/5-inch) in size. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IB2The cancer is at least 2 cm in size but not larger than 4 cm. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IB3The cancer is at least 4 cm in size and limited to the cervix. It has not spread to nearby lymph nodes. It has not spread to distant sites.
II The cancer has grown beyond the cervix and uterus, but hasn’t spread to the walls of the pelvis or the lower part of the vagina. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IIAThe cancer has grown beyond the cervix and uterus but has not spread into the tissues next to the cervix (called the parametria). It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IIA1The cancer is not larger than 4 cm (about 1 3/5 inches). It not has not spread to nearby lymph nodes. It has not spread to distant sites.
 IIA2The cancer is 4 cm or larger. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IIBThe cancer has grown beyond the cervix and uterus and has spread into the tissues next to the cervix (the parametria). It has not spread to nearby lymph nodes. It has not spread to distant sites.
III The cancer has spread to the lower part of the vagina or the walls of the pelvis. The cancer may be blocking the ureters (tubes that carry urine from the kidneys to the bladder). It might or might not have not spread to nearby lymph nodes. It has not spread to distant sites.
 IIIAThe cancer has spread to the lower part of the vagina but not the walls of the pelvis. It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IIIBThe cancer has grown into the walls of the pelvis and/or is blocking one or both ureters causing kidney problems (called hydronephrosis). It has not spread to nearby lymph nodes. It has not spread to distant sites.
 IIICThe cancer can be any size. Imaging tests or a biopsy show the cancer has spread to nearby pelvic lymph nodes (IIIC1) or para-aortic lymph nodes (IIIC2). It has not spread to distant sites.
IV The cancer has grown into the bladder or rectum or to far away organs like the lungs or bones.
 IVAThe cancer has spread to the bladder or rectum or it is growing out of the pelvis.
 IVBThe cancer has spread to distant organs outside the pelvic area, such as distant lymph nodes, lungs or bones. Metastasis is greatest.

How is cervical cancer prevented?

  • Gardasil 9 vaccine helps prevent infection from HPV-16,HPV-18, and 5 other types of HPV linked to cancer. It can also prevent the 2 low-risk types of HPV known to cause 90% of genital warts(Finocchario-Kessler et al., 2016)(Heard et al., 2017).

The U.S. Food and Drug Administration (FDA) approved Gardasil 9 for everyone between the ages of 9 and 45. The U.S. Centers for Disease Control (CDC) recommends HPV vaccination for everyone through the age of 26 if not already vaccinated. Vaccination is not recommended for everyone older than age 26.

Some adults between the ages of 27 and 45 who have not already been vaccinated may decide to get it after reviewing their risks for infection and benefits of the vaccine with their doctor. Teenagers (both genders) should get the vaccination before they become sexually active. If you are already having sex, you should still talk with your health care team about getting the vaccine. Even if you have 1 type of HPV, the vaccine may protect you from the types of HPV you do not have. Vaccinating the boys is crucial in cutting the cycle for spread and recurrent infection with HPV.

  • Early detection and treatment of precancerous lesions is another form prevention of cervical cancer. This achieved by screening(Sankaranarayanan, 2014).
  • Responsible sexual practices can help reduce your risk of HPV. Limiting your number of sex partners is another way to reduce risk. Using a condom cannot fully protect you from HPV during sex as its transmission is more of contact of body with fluids from someone with HPV infection. Sharing of paraphernalia should be discouraged.

Is the HPV vaccine safe and effective?

Studies show that the HPV vaccine is safe and prevents lasting infections. They also show that the vaccine reduces precancerous lesions. Recent research suggests that reducing precancerous lesions results in less cancer.

WHO recommends screening every 5 years from 26-30 years of age.

Treatment.

At early stages,cancer is treatable while as it progresses to later stages only palliative care can be given. Its best to initiate early diagnosis for better outcomes.

Treatment options are;

  1. Surgery.

May include hysterectomy which is removal of uterus.

Radiation.

Use of radiation energy to kill cancer cells.

  • Chemotherapy.

Administration of anticancer drugs either by oral or  injections. There are programs such as clinical trials in a research study in which one or more human subjects are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes. 

  • Immunotherapy(Gupta et al., 2020)(296 Proc. Roy. Soc. Med. Volume 67 April 1974 Patient’s, 1980). Use of immune stimulants and booster to enable the immune system to fight cancer.
  • Palliative care.

Done as clinical symptomatic management with main goal of treatment being to reduce and or manage pain.

TAKE HOME.

  1. Early cancer screening is key in the diagnosis and fight against cancer.
  2. Vaccination of all teenage genders is encouraged to prevent. Note even the boys must be vaccinated.
  3. Its important for the men to look out after women’s health just as much as they do theirs.

References.

296 Proc. roy. Soc. Med. Volume 67 April 1974 patient’s. (1980). 67(April 1974), 1980.

Durowade, K. A., Babatunde, O. A., Omokanye, L. O., Elegbede, O. E., Ayodele, L. M., Adewoye, K. R., Adetokunbo, S., Olomofe, C. O., Fawole, A. A., Adebola, O. E., & Olaniyan, T. O. (2017). Early sexual debut : prevalence and risk factors among secondary school students. Afri Health Sci., 17(3), 614–622.

Finocchario-Kessler, S., Wexler, C., Maloba, M., Mabachi, N., Ndikum-Moffor, F., & Bukusi, E. (2016). Cervical cancer prevention and treatment research in Africa: A systematic review from a public health perspective. BMC Women’s Health, 16(1). https://doi.org/10.1186/s12905-016-0306-6

Gupta, S., Gupta, S. C., Hunter, K. D., & Pant, A. B. (2020). Immunotherapy: A New Hope for Cancer Patients. Journal of Oncology, 2020. https://doi.org/10.1155/2020/3548603

Heard, I., Tondeur, L., Arowas, L., Demazoin, M., Falguières, M., & Du Chatelet, I. P. (2017). Effectiveness of human papillomavirus vaccination on prevalence of vaccine genotypes in young sexually active women in France. Journal of Infectious Diseases, 215(5), 757–763. https://doi.org/10.1093/infdis/jiw639

Kim, H. W., Kim, D. H., & Kim, Y. (2018). Men’s awareness of cervical cancer: A qualitative study 11 Medical and Health Sciences 1117 Public Health and Health Services. BMC Women’s Health, 18(1), 1–10. https://doi.org/10.1186/s12905-018-0650-9

Sankaranarayanan, R. (2014). Screening for cancer in low- and middle-income countries. Annals of Global Health, 80(5), 412–417. https://doi.org/10.1016/j.aogh.2014.09.014

Published by Oliver Adeka

A human rights advocate, a lover of life, a care giver, a pharmacy practitioner augmented with patient safety.

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