Most young women die from cervical cancer which has turned out to be a
notable public health issue in Nigeria and yet it is preventable.
INTRODUCTION.
Cervical cancer is a malignant cancer
of the cervix uteri or cervical area. This disease causes the cells of
the cervix to grow abnormally. If not treated early, it can cause
death. Signs and symptoms include irregular bleeding from the vagina such
as bleeding after menopause or after sexual intercourse.
It may also present with vaginal bleeding but symptoms may be absent until the
cancer is in its advanced stages. Treatment consists of local excision in
its early stages and chemotherapy and radiotherapy in advanced stages of the
disease.
Pap smear screening can identify potentially pre-cancerous changes.
Treatment of high grade changes can prevent the development of cancer. In
developed countries, the widespread use of cervical screening programs has
reduced the incidence of invasive cervical cancer by 50% or more.
Human papillomavirus(HPV) infection is a necessary factor in the development of
nearly all cases of cervical cancer. HPV vaccine is effective against the
two strains of HPV that cause most cervical cancer. It has been licensed
in the United States and European Union. These two HPV strains together
are currently responsible for approximately 70% of all cervical cancers.
Since the vaccine only covers some high-risk types, women should seek regular
Pap smear screening even after vaccination.
About 0.5% of cervical cancers occur in pregnant women and about one third of
women are under 35 years when given the diagnosis. The survival rates for
the pregnant versus the non-pregnant woman are very similar. It is safe
to have a Pap smear during a prenatal stage.
TYPES OF CERVICAL CANCER.
There are two types of cervical cancer - Squamous cell cancer and
Adenocarcinoma. These are both named after the type of cell that becomes
cancerous. In the early stages of the disease known as 1A and 1B, the
cancer starts to grow into the deeper tissues of the cervix. This is treated
with surgery or radiotherapy.
The same treatment is given for stages
2A and 2B where the cancer spreads around the neck of the womb.
In stages 3A and 3B, the cancer spreads
into the pelvis; this is treated with radiotherapy and chemotherapy.
The most serous stages of the disease are 4A and 4B, where the cancer spreads
to other organs. This often includes a combination of surgery,
radiotherapy and chemotherapy.
CAUSES OF THE DISEASE
The HPV infection is a necessary factor in the development of almost all cases of
cervical cancer. It happens when normal cells in the cervix change into
cancerous cells.
This change normally takes several years – 5 to 30, but can also happen in a
short amount of time before the cells turn into abnormal cells developed on the
cervix that can be found by a Pap test
Prior to diagnosis, cervical cancer wasn’t given the attention it
requires. Although the number of cases of the disease has halved in
recent years, it remains the second most common cancer in women under the age
of 35.
To start with, cervical cancer affects the cervix - the lower part of the womb,
also known as the uterus. According to Macmillan Cancer Support, it can
take many years to develop.
It occurs when abnormal cells contained in the cervix known as cervical intraepithelial
neoplasia (CIN), become diseased. CIN is as a result of virus infection
referred to as the human papillomavirus(HPV). It is mainly passed on
during sexual intercourse.
Most women who have had unprotected sexual intercourse in their lives will contract
the virus but in most cases, their immune system removes it and they won’t know
they’ve had it. Women are said to be more prone to developing cervical
cancer if they:
-- smoke,
-- start to have sex at an early age,
-- have many sexual partners,
-- have taken the contraceptive pill
for a long time, or
-- have a weakened immune system such
as in HIV infected women.
These are referred to as behavioral
risk factors.
SIGNS AND SYMPTOMS
The early stages of cervical cancer may be completely asymptomatic; vagina
bleeding contact bleeding or a vaginal mass may indicate the presence of
malignancy. Also, moderate pain during sexual intercourse and vaginal discharge
are symptoms of cervical cancer.
In advanced disease, metastasis may be
present in the abdomen and lungs or elsewhere.
Symptoms of advanced cervical cancer may include among others:
-- loss of appetite,
-- weight loss,
-- fatigue,
-- pelvic pain,
-- back pain,
-- leg pain,
-- single swollen leg,
-- heavy bleeding from the vagina,
-- leaking of urine or faeces from the
vagina, and
-- bone fractures.
PREVENTIVE MEASURES.
Regular screening can increase the survival rate of cervical cancer by
75%. In order to identify and treat CIN cells in good time, women must
have smear tests. About 4.4 million women are invited for cervical
screening each year in England with about 24000 of them having a severely
abnormal cervical screening result.
Women are invited to attend a smear test from the age of 25 to 65 although, if
sexually active, women are encouraged to come for testing from the age of 20. They
are given every three years up until the age of 49 and then every five years
from the ages of 50 to 64.
TESTING AND SCREENING.
The test itself involves inserting a spatula into the vagina to take a sample
of cells. These cells are then taken to the clinical laboratory for inspection.
Although slightly an uncomfortable procedure, it is quick, painless and saves
lives.
At least women should go for testing once every year. The good news is
that, if spotted early enough, cervical cancer is very treatable. So it is
important that women everywhere take regular smear tests.
The most serious stages of the disease are 4A and 4B, where the cancer spreads
to other organs. This often includes a combination of surgery, radiotherapy
and chemotherapy.
It has been observed that less than 0.1% of Nigerian women avail themselves
this screening and less than 1% Are aware of the existence of this killer
disease, thereby killing a woman every one hour. Although it is the
easiest of all cancers to prevent, cervical cancer kills more 24-35 year old
women in our society than any other cancer in any other part of the world.
The World Health Organization (WHO) has projected a 25% rise in the disease
over the next decade in the absence of widespread intervention.
It takes about N1000 only (local Nigerian currency) to screen one woman, but a
good number of under privileged ones cannot afford it. Therefore, it is
imperative for the government to invest in it and save mothers’ lives from this
preventable disease.
TREATMENT OF CERVICAL CANCER.
MICRO-INVASIVE cancer (Stage 1A) is usually treated by hysterectomy,
which means removal of the whole uterus including part of the vagina. For
stage 2A, the lymph nodes are removed as well. An alternative for patients
who desire to remain fertile is a local surgical procedure(LEEP) or cone
biopsy.
If a cone biopsy does not produce clear margins, one more possible treatment
option for patients, who want to preserve their fertility is a
trachelectomy. This attempts to surgically remove the cancer while
preserving the ovaries and uterus, providing for a more conservative operation
than a hysterectomy.
It is a viable option for those in stage 1 cervical cancer, which has not
spread. However, it is not yet considered a standard cure , as few
doctors are skilled in this procedure. Even the most experienced surgeon
cannot promise that a trachelectomy can be performed until after surgical
microscopic examination, as the extent of the spread of cancer is
unknown.
If the surgeon is not able to microscopically confirm clear margins of cervical
tissue once the patient is under general anesthesia in the operating room, a
hysterectomy may still be needed.
This can only be done during the same operation, if the patient has given prior
consent. Due to the possible risk of the cancer spreading to the lymph
nodes in stage 1B cancers and some stage 1A cancers, the surgeon may also need
to remove some lymph nodes from around the uterus for pathologic evaluation.
A radical trachelectomy can be performed abdominally or vaginally and there are
conflicting opinions as to which is better. A radical abdominal
trachelectomy with lymphadenectomy usually only requires a two to three day
hospital stay and most women recover very quickly.
Complications are uncommon, although women who are able to conceive after
surgery are susceptible to pre-term labour and possible late miscarriage.
It is generally recommended to wait at least one year before attempting to
become pregnant after surgery.
Recurrence in the residual cervix is very rare if the cancer has been cleared
with the trachelectomy. Yet, it is recommended for patients to practice
vigilant prevention and follow up care including pap screenings, colposcopy,
with biopsies of the remaining lower uterine segment as needed every 3-4 months
for at least 5 years-to monitor for any recurrence in addition to minimizing
any new exposures to HPV through safe sex practices until one is actively
trying to conceive.
Early stages less than 4cm can be treated with radical hysterectomy with
removal of the lymph nodes or radiation therapy. Radiation therapy is
given as external beam radiotherapy to the pelvis and brachytherapy.
Patients who have high risk features found on pathologic examination are
treated with surgery and chemotherapy in order to reduce the risk of relapse.
Larger early stage tumors more than 4cm may be treated with radiation therapy
and cisplatin-based chemotherapy, hysterectomy or cisplatin chemotherapy
followed by hysterectomy.
Advanced stage tumors are treated with radiation therapy and cisplatin-based
chemotherapy. On June 15, 2006, the US Food and Drug Administration
approved the use of a combination of two chemotherapy drugs, hycamtin and
cisplatin for women with a late-stage cervical cancer treament.
Combination treatment has significant risk of neutropenia, anemia and
thrombocytopenia side effects.
