Cancer from A to Z

Cancer of the cervix is highly preventable. Regular Pap smears not only detect cancerous cells, but also abnormal changes in the cervix that can eventually progress to cancer over a period of 10 to 15 years.

A sexually transmitted virus called the human papillomavirus (HPV) causes almost all cases of cervical cancer. HPV usually goes away by itself, and most people with HPV never even know they have it. And while experts point out that most women infected with HPV will not develop cervical cancer, doctors urge women to be aware of that risk, and to get Pap smears regularly.

HPV can be categorized into two groups:

Low Risk - Two of the low-risk HPV strains are 6 and 11. Some HPV strains can cause genital warts but do not cause cervical cancer. These low-risk strains account for about 90% of genital warts.

High risk - Two high-risk types of HPV, strains 16 and 18, may stimulate the growth of precancerous cells in the cervix. If these abnormal cells are not found and treated, they may become cancerous. They account for about 70% of all cervical cancers and a smaller percentage of vaginal and vulval cancers.

 
Other Risk Factors Include:
Age: The risk of cervical cancer increases with age and most often is diagnosed in women over the age of 40. However, younger women are often diagnosed with precancerous lesions that require treatment to prevent cancer.

Smoking: Cigarette smoke contains chemicals that damage the body's cells. It increases the risk of precancerous changes in the cervix, especially in women with HPV.

Sexual behavior: Certain types of sexual activity may increase a risk of getting HPV infection such as multiple sexual partners, or high-risk male partners, first intercourse at an early age and using non-barrier birth control methods.

Lack of regular Pap tests: Cervical cancer is more common among women who have no prior Pap smear screening. The Pap test helps doctors find precancerous cells.

Sexually transmitted diseases: Women with an STD have a higher risk of cervical cancer.

Diethylstilbestrol (DES) exposure before birth

HIV infection

Weakened immune system: Women who have undergone an organ transplant or take steroids for other reasons have a higher than average risk of developing cervical cancer.

 
Cervical Cancer Prevention
HPV Vaccine

HPV vaccines have the potential for preventing cervical cancer. A new vaccine offers protection from the virus that causes most cervical cancers by blocking the infection. The drug was approved by the Food and Drug Administration (FDA) in June 2006.

Routine vaccination is recommended for females ages 11 to 26. The vaccine is most effective when given to girls between the ages of 11 to 12. Three doses of the vaccine are given by injection during a six-month period.

Pap test
A Pap test, often called a Pap smear, is a screening procedure used to detect abnormal cells in and around the cervix. In this test, the doctor uses a stick or brush to take a few cells from the cervix. An abnormal result could mean inflammation of the cervix, trichomonas or yeast infection, or other causes. In postmenopausal women, the Pap test could detect abnormal glandular cells that could indicate endometrial cancer.

Women should have a Pap test beginning three years after starting vaginal intercourse and no later than age 21.

At age 30, women with three or more consecutive exams with normal results may have a Pap smear performed less frequently. This is dependent on risk factors and should be discussed with the doctor.

Women who have been treated for cervical dysplasia (a precancerous lesion) or cancer may need to have a Pap smear more frequently if recommended by the doctor.

If you have had a hysterectomy, ask your doctor about screening. If you are healthy, had the hysterectomy for a reason other than precancer or cancer, and have normal Pap tests, then you may be screened less frequently. But even if your cervix was removed during your hysterectomy, regular pelvic exams are still recommended to check for precancerous cells in the vaginal and vulva area, especially for those who have been exposed to HPV.

Research to improve detection and screening methods for cervical cancer is ongoing. Some of these advancements may still be in the investigational stage and not yet approved or available.

Because cervical cancer is highly treatable when detected in an early stage, many studies are looking at developing better ways to detect cervical cancer, such as fluorescent spectroscopy. This method uses fluorescent light to detect changes in precancerous cells in the cervix.

A newer Pap test method known as the Thin Prep test transfers a thin layer of cells onto a slide. Because this sample can be preserved, a testfor HPV can be done at the same time. (A regular Pap smear tests for the presence of abnormal cells, not the virus.)

Tests & Procedures
If you have symptoms or Pap test results that suggest precancerous cells or cancer of the cervix, your doctor will suggest other procedures to make a diagnosis. The first step is usually colposcopy, in which the doctor examines the cells of the cervix more closely. Another common test to more closely examine the cells is a biopsy, in which a sample of cervical cells is taken for examination.

 
Colposcopy
Colposcopy is a diagnostic test used to evaluate an area of abnormal tissue on the cervix, vagina, or vulva using an instrument called a colposcope. A colposcope looks like a pair of binoculars on a stand. It magnifies tissue so a healthcare practitioner can see abnormalities that cannot be seen with the naked eye.

 
Biopsy
In a biopsy, your doctor removes a small amount of tissue for examination under a microscope to look for precancerous cells or cancer cells. Most women have the biopsy in the doctor's office, and no anesthesia is needed.

Different types of cervical biopsies include:

Punch biopsy: The tissue sample is removed from the cervix using biopsy forceps, an instrument used to grasp tissue firmly and then remove it. This procedure is usually performed in your gynecologist's office and does not require anesthesia.

Endocervical curettage (ECC): A tissue sample is scraped from an area just past the opening of the cervix using a curette (small, spoon-shaped instrument) or a thin, soft brush. This can be done in your doctor's office and does not require anesthesia.

LEEP (Loop Electro-Surgical Excision Procedure): The LEEP is performed using a small heated wire to remove tissue and precancerous cells from the cervix. This procedure can be done in your doctor's office and requires local anesthesia.

Cone biopsy (also called LEEP cone or cold knife cone biopsy): A cone-shaped sample of tissue is removed from the cervix so that the pathologist can see if abnormal cells are in the tissue beneath the surface of the cervix. This specimen is much bigger than the biopsy done in the office without anesthesia. A sample of tissue can be removed for a cone biopsy using a LEEP cone procedure, which can be done in the doctor's office under local anesthesia, or a knife cone procedure, done in an operating room under local or general anesthesia.

 
Cystoscopy and Proctoscopy
If advanced cancer is diagnosed and your doctor suspects the cancer may have spread beyond the cervix, a cytoscopy or proctoscopy may be done using a lighted tube to view the inside of the bladder (cystoscopy) or the anus, rectum and lower colon (proctoscopy).

 
Imaging
To learn more about the extent of disease and suggest a course of treatment, the doctor may order some of the following imaging tests:

Chest X-ray: This is a picture of the chest that shows your heart, lungs, airway, blood vessels and lymph nodes. A chest X-ray can often show whether cancer has spread to the lungs.

Computed tomography (CT) scan: This diagnostic test uses an X-raymachine and a computer to create detailed pictures of the body, including 3-D images. It is used to detect disease outside the cervix or abnormal organ structure. CT scans also can be used to guide a needle into a mass if a biopsy is needed.

Magnetic resonance imaging (MRI): This diagnostic test uses magnetic fields and radio waves to create computerized pictures of the pelvis and abdomen. You may have to be placed in a tube, which can feel confining to people who have a fear of enclosed spaces.

Treatment of cervical cancer will depend on a number of factors, including:

• The stage of the cancer
• The size of the tumor
• The patient's desire to have children
• The patient's age and overall health

Treating cervical cancer when a woman is pregnant depends on two factors: the stage of pregnancy and the stage of cervical cancer. Treatment may be delayed until the baby is born if a woman is in her third trimester of pregnancy. Treatment may also be delayed in pregnant women if cervical cancer is detected before it has spread.

Surgery

Small Precancerous Lesions
The following surgical procedures may be used for precancerous lesions or for cancerous tissue that has not spread beyond the cervix.

Cryosurgery (cryotherapy): This surgical procedure uses an instrument to freeze and destroy precancerous tissue.

Laser surgery: This surgical procedure uses a narrow laser beam to destroy precancer cells. This is not used on invasive cancer. A benefit of laser treatment is its precision; it destroys only diseased tissue inside in the cervix.

LEEP (loop electrosurgical excision procedure): This procedure uses electrical current passed through a thin wire hook. This is primarily used on precancerous lesions under local anesthesia. The advantage of this procedure is that more of the tissue can be removed for evaluation.

Cone: A gynecologist uses the same procedure as a cone biopsy to remove all of the cancerous tissue. This procedure can be used in a woman who has a very small cancerous area and who wishes to preserve the ability to have children.

Hysterectomy: This operation removes the uterus and the cervix. This kind of hysterectomy is performed only on women with cervical cancer less than three millimeters in depth.

Bilateral salpingo-oophorectomy: In this procedure, the fallopian tubes and ovaries are removed at the same time as the hysterectomy. If a woman is close to the age of menopause, her doctor may discuss removing her ovaries and fallopian tubes to reduce the chance that the cancer will recur in one of those organs.

 
Large Cervical Cancer Lesions
The following surgical procedures may be used for larger cervical cancerlesions (usually up to four to five centimeters in width), but only if the cancer is all within the cervical tissue. If the cancer has spread beyond the cervix, doctors will usually recommend chemotherapy in combination with radiation therapy.

Trachealectomy: This procedure removes the cervix and surrounding tissue but not the uterus. It is used for women who have a larger cancerous area but wish to preserve the ability to have children. The procedure may include removal of lymph nodes. Typically patients considered for this procedure have to have tumors less than two centimeters in size.

Radical hysterectomy: The surgeon removes the cervix, uterus, part of the vagina and the tissues surrounding the cervix called the parametria. At the same time, the surgeon also removes nearby lymph nodes. Depending on a woman's age and the size of the tumor, she may also have a bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes).

Radiation Therapy
Radiation therapy is used for cancers that have spread beyond the cervix (II, III or IV) or very large lesions (larger than four centimeters).

Radiation therapy uses high-energy X-rays or other types of radiation to kill cancer cells or shrink the tumor. Radiation therapy is used instead of surgery in most cases. However, it is sometimes necessary after surgery if it is discovered that the cancer has spread outside the cervix, or to reduce the risk that a cancer will come back after surgery.

There are two types of radiation therapy:

External radiation therapy uses a machine outside the body to send radiation toward the cervical cancer. Internal radiation therapy uses a small amount of radioactive material that is delivered directly to the tumor using implants.
Internal radiation therapy implants are inserted through the vagina into the cervix, where they are placed next to the tumor while the patient is under anesthesia. The implants stay in place for a few days.
 

Types of radiation therapy are used with this disease:
Virtual CT simulation
Intensity modulated radiation therapy (IMRT)
Volumetric Modulated Arc Therapy (VMAT)
Brachytherapy

• Gynecologic brachytherapy consists of implanting a device in the cavity of the vagina or neck of the womb through which radiation is delivered by means of a radioactive source of Ir-192. The technique has the advantage that a low-volume, high-intensity dose of radiation can be delivered whilst protecting the surrounding healthy tissue from the Iridium source.
  High-dose brachytherapy (HDR) has the advantage that it is safer for those handling the radiation and for the patient, as there is no need for the patient to be isolated or admitted to hospital being an ambulatory treatment.

Types of brachytherapy administered (combined or not with external radiation treatment).

1. Endocavitary brachytherapy is used as an adjuvant therapy in surgery on endometrial tumors, where we treat the vaginal vault in uterine tumors, cervical tumors, primary vaginal tumors or relapse of other vaginal tumors.
2. Interstitial brachytherapy: requires sedation. Locally advanced cervical tumors.

Intraoperative radiation therapy

• We apply this technique when treating patients with a relapsed tumorpreviously treated with radiation. Radiation therapy is applied during surgery when the surgeon has just resected the tumor, but where the margins are suspected of not being negative. Radiation is delivered during surgery by means of a source of Iridium 192.
   

Chemotherapy

Chemotherapy uses drugs to stop the growth of cancer cells either by killing the cells or by stopping them from dividing. Chemotherapy can be given by mouth or injected into a vein or muscle. In most cases, it is given to a patient through a vein during an outpatient visit using systemic chemotherapy. The drugs enter the bloodstream and can reach cancer cells throughout the body.

Regional chemotherapy is chemotherapy which is placed directly into an organ or a body cavity, such as the abdomen. Almost all cervical cancerpatients in good medical condition who are receiving radiation for stage IIA or higher, will be offered chemotherapy in addition to radiation therapy.