WORLD CANCER DAY: CERVICAL CANCER

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Pauline had reported with vaginal spotting and painful sex. She was from South Africa and had been irregular with her health care or routine check-ups. She was married with six .children at 53 years, and had already witnessed menopause. Her first sexual contact had been at 12years, after a gang rape. Subsequently, she had 6 more partners, and felt the pain and bleeding had resulted from some form of friction, due to vaginal dryness while having sexual intercourse. She was later on diagnosed with Stage 2 cervical cancer, after a series of medical examinations.

What is cervical cancer?

 

The uterine cervix is the lowest portion of a woman’s uterus (womb), connecting the uterus with the vagina. The cervix is the area of a female’s body between her vagina and uterus.

Cervical cancer therefore occurs when the cells of the cervix grow abnormally, multiply rapidly and invade other tissues and organs of the body. When it is invasive, this cancer affects the deeper tissues of the cervix and may have spread to other parts of the body (metastasis), most notably the lungs, liver, bladder, vagina, and rectum.

However, cervical cancer is slow-growing, and is almost 100% preventable, so its progression through precancerous changes provides opportunities for prevention, early detection, and treatment.

Early detection is key to cervical cancer prevention and treatment.

Most women diagnosed with precancerous changes in the cervix are in their 20s and 30s, but the average age of women when they are diagnosed with cervical cancer is the mid-50s. This difference in the age at which precancerous changes are most frequently diagnosed and the age at which cancer is diagnosed highlights the slow progression of this disease and the reason why it can be prevented if adequate steps are taken.

Incidence in Africa

 

In Africa, women aged 15 years and older, are at risk of developing cervical cancer, as approximately 80,000 women are diagnosed with cervical cancer per year, and just more than 60,000 women die from the disease.

 

Causes/Risk Factors

  • Infection with human papillomavirus (HPV).

 

  • Early sexual contact and multiple sexual partners.

 

  • Taking oral contraceptives (birth control pills) increase the risk of cervical cancer because they lead to greater exposure to HPV.

 

  • Forms of HPV, a virus whose different types cause skin warts, genital warts, and other abnormal skin disorders, have been shown to lead to many of the changes in cervical cells that may eventually lead to cancer. Certain types of HPV have also been linked to cancers involving the vulva, vagina, penis, anus, tongue, and tonsils. Genetic material that comes from certain forms of HPV (high-risk subtypes) has been found in cervical tissues that show cancerous or precancerous changes.

 

  • Women who have been diagnosed with HPV are more likely to develop a cervical cancer.

 

  • Girls who begin sexual activity before age 16 or within a year of starting their menstrual periods are at high risk of developing cervical cancer.

 

  • Cigarette smoking is another risk factor for the development of cervical cancer. The chemicals in cigarette smoke interact with the cells of the cervix, causing precancerous changes that may over time progress to cancer. The risk of cervical cancer in cigarette smokers is two to five times that of the general population.

 

  • Oral contraceptives (“the pill”), especially if taken longer than five years, may increase the risk for cervical cancer because they reduce the use of condoms.

 

  • Women who were exposed to a medicine called diethylstilbestrol (DES) while their mothers were pregnant are also at risk for cervical cancer. This medicine is a type of estrogen that doctors thought could prevent miscarriage. However, DES has been linked with causing abnormal cells in the cervix and vagina.

 

What are the symptoms of Cervical Cancer?

As in many cancers, you may have no signs or symptoms of cervical cancer until it has progressed to a dangerous stage. They may include:

  • Pain, when the cancer is advanced.

 

  • Abnormal vaginal bleeding, such as bleeding between menstrual periods, after sex, after a pelvic exam, or after menopause.

 

  • Abnormal vaginal discharge- discharge that is unusual in amount, color, consistency, or smell

 

  • Pelvic pain.

 

  • Kidney failure due to a urinary tract or bowel obstruction, when the cancer is advanced

NOTE: WHEN TO SEE A HEALTH PROVIDER

The range of conditions that can cause vaginal bleeding are diverse and may not be related to cancer of the cervix. They vary based on your age, fertility, and medical history. Vaginal bleeding after menopause is never normal. If you have gone through menopause and have vaginal bleeding, see your health care provider as soon as possible. Very heavy bleeding during your period or frequent bleeding between periods warrants evaluation by your health care provider. Bleeding after intercourse, especially after vigorous sex, does occur in some women. If this occurs only occasionally, it is probably nothing to worry about. Evaluation by your health care provider is advisable, especially if the bleeding happens repeatedly. If you have vaginal bleeding that is associated with weakness, feeling faint or light-headed, or actual fainting, go to a hospital emergency department for care.

Types

  • Most (up to 9 out of 10) cervical cancers are squamous cell carcinomas.

 

  • The second types are These are cervical cancers that develop from gland cells.

 

  • Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomasor mixed carcinomas.

 

Cervical Cancer Stages:

The stage of a cancer is a measure of how far it has progressed, namely, what other organs or tissues have been invaded.

  • Stage 0: The earliest stage of cervical cancer. More than 90% of women survive at least five years after diagnosis.
  • Stage I (Five-year survival rate of 80 – 93%.):The cancer has spread from the cervix lining into the deeper tissue but is still just found in the uterus. It has not spread to lymph nodes or other parts of the body. This stage may be described in more detail (see below).
  • Stage IA: The cancer is diagnosed only by microscopy, which is viewing cervical tissue or cells under a microscope. No lymph nodes are involved, and there is no distant spread.
  • Stage IA1: There is a cancerous area of 3 millimeters (mm) or smaller in depth and 7 mm or smaller in length. No lymph nodes are involved, and there is no distant spread.
  • Stage IA2: There is a cancerous area larger than 3 mm but not larger than 5 mm in depth and 7 mm or smaller in length. No lymph nodes are involved, and there is no distant spread.
  • Stage IB:In this stage, the doctor can see the lesion, and the cancer is found only in the cervix, or there is a lesion that can be seen using a microscope, and it is larger than a stage IA2 tumor (see above). The cancer may have been found through a physical examination, laparoscopy, or other imaging method. No lymph nodes are involved, and there is no distant spread.
  • Stage IB1: The tumor is 4 centimeters (cm) or smaller. No lymph nodes are involved, and there is no distant spread.
  • Stage IB2: The tumor is larger than 4 cm. No lymph nodes are involved, and there is no distant spread.
  • Stage II (Five-year survival rate of 58 – 63%.):The cancer has spread beyond the cervix to nearby areas, such as the vagina or tissue near the cervix, but it is still inside the pelvic area. It has not spread to lymph nodes or other parts of the body. This stage may be described in more detail (see below).
  • Stage IIA:The tumor has not spread to the tissue next to the cervix, also called the parametrial area. No lymph nodes are involved, and there is no distant spread.
  • Stage IIA1:The tumor is 4 cm or smaller. No lymph nodes are involved, and there is no distant spread.
  • Stage IIA2:The tumor is larger than 4 cm. No lymph nodes are involved, and there is no distant spread.
  • Stage IIB:The tumor has spread to the parametrial area. No lymph nodes are involved, and there is no distant spread.
  • Stage III (cervical cancer rate is anywhere from 32 – 35%)The tumor has spread to the pelvic wall, and/or involves the lower third of the vagina, and/or causes swelling of the kidney, called hydronephrosis, or stops a kidney from functioning. No lymph nodes are involved, and there is no distant spread.
  • Stage IIIA:The tumor involves the lower third of the vagina, but it has not grown into the pelvic wall. No lymph nodes are involved, and there is no distant spread.
  • Stage IIIB: The tumor has grown into the pelvic wall and/or affects the kidneys, but it has not spread to the lymph nodes or distant sites. Or, the cancer has spread to lymph nodes in the pelvis, but not distant sites, and the tumor can be any size.
  • Stage IVA:The cancer has spread to the bladder or rectum and may or may not have spread to the lymph nodes, but it has not spread to other parts of the body.
  • Stage IVB: The cancer has spread to other parts of the body. 16% or fewer women with stage IV cervical cancer survive five years.

Exams and Tests

  • As with all cancers, an early diagnosis of cervical cancer is key to successful treatment and cure. Treating precancerous changes that affect only the surface of a small part of the cervix is much more likely to be successful than treating invasive cancer that affects a large portion of the cervix and has spread to other tissues.

 

  • The most important progress that has been made in early detection of cervical cancer is widespread use of the Papanicolaou test (Pap smear) and high-risk HPV testing.

 

  • A Pap smear is done as part of a regular exam. During the procedure, cells from the surface of the cervix are collected and examined for abnormalities. Diagnosis of cervical cancer requires that a sample of cervical tissue (called a biopsy) be taken and analyzed under a microscope. This would be done if the Pap smear is abnormal.

 

  • Colposcopy is a procedure similar to a pelvic exam. It is usually used for a patient who had an abnormal Pap smear result but a normal physical exam. The examination uses a type of microscope called a colposcope to inspect the cervix.

 

  • The loop electrosurgical excision procedure (LEEP) technique uses an electrified loop of wire to take a sample of tissue from the cervix. This procedure can often be performed in your gynecologist’s office.

 

  • A conization (removal of a portion of the cervix) is performed in the operating room while you are under anesthesia. It can performed with a LEEP, with a scalpel (cold knife conization) or a laser. In this procedure, a small cone-shaped portion of your cervix is removed for examination. LEEP or cold knife conization procedures result in tissue samples in which the types of cells and how much they have spread to underlying areas can be more fully determined. They can be used to diagnose problems or to treat known problems.

Precancerous changes

Precancerous changes are now most often called squamous intraepithelial lesion (SIL). “Lesion” refers to an area of abnormal tissue; intraepithelial means that the abnormal cells are present only in the surface layer of cells. Changes in these cells can be divided into two categories:

Low-grade SIL (LGSIL): Early, subtle changes in the size and shape of cells that form on the surface of the cervix are considered low grade. These lesions may go away on their own, but over time, they may become more abnormal, eventually becoming a high-grade lesion. LGSIL is also called mild dysplasia or cervical intraepithelial neoplasia 1 (CIN 1). These early changes in the cervix most often occur in women ages 25 to 35 years, but can appear in women of any age.

High-grade SIL (HGSIL): A large number of precancerous cells, which look very different from normal cells, constitute a high-grade lesion. Like low-grade SIL, these precancerous changes involve only cells on the surface of the cervix. These lesions are also called moderate or severe dysplasia, CIN 2 or 3, or carcinoma in situ. They develop most often in women ages 30 to 40 years, but can occur at any age. Precancerous cells, even high-grade lesions, usually do not become cancerous and invade deeper layers of the cervix for many months, perhaps years.

Prevention

  1. The key to preventing invasive cervical cancer is to detect any cell changes early, before they become cancerous. Regular pelvic exams and Pap tests are the best way to do this. How often you should have a pelvic exam and Pap test depends on your individual situation, but here are guidelines:
  • Make sure you get a Pap test to check for cervical cancer every 3 years if you are 21 or older.

 

  • If you are 30-65, you can get both a Pap test and human papillomavirus ( HPV ) test every 5 years. Older than that, you may be able to stop testing if your doctor says you are low risk.

 

  • Women of any age who’ve had a hysterectomy, with removal of the cervix and no history of cervical cancer or pre cancers do not need to be screened, according to the guidelines.

 

  • If you are sexually active and have a higher risk for STDs, get tests for chlamydia, gonorrhea, and syphilis yearly. Take an HIV test at least once, more frequently if you’re at risk.

 

  1. Avoidance of HPV infection is important in the prevention of precancerous and cancerous changes of the cervix. Prevention measures include:
  • Abstinence from sex is recommended as one way to prevent the transmission of HPV.

 

  • Likewise, barrier protection, such as condom use, may reduce the risk of HPV infection, although this has not yet been fully studied.

 

  • Vaccines to protect women from cervical cancer and men from HPV are now available.

 

  • Gardasil is approved for use in males and females ages 9 to 26. It protects against two strains of HPV (types 16 and 18) that account for the development of 70% of cervical cancers and over 50% of precancerous lesions of the cervix, vulva, and vagina. Gardasil protects against the types of HPV (6 and 11) which are associated with over 90% of the cases of genital warts.

 

  • Gardasil 9 can also be used in males and females ages 9 to-26. It prevents infection by the same HPV types as Gardasil plus HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58. Collectively, these types are implicated in 90% of cervical cancers.
  1. Cigarette smoking is another risk factor for cervical cancer that can be prevented. Quitting smoking may decrease your chances of developing the disease.

4. Engage in mild physical activity to keep up your energy level. Make sure it doesn’t wear you out.

5. Get enough rest at night, and take naps if needed.

6. Avoid / Limit alcohol. .

 

For cervical cancer, the survival rate is close to 100% when precancerous or early cancerous changes are found and treated. The prognosis for invasive cervical cancer depends on the stage of the cancer when it is found.

 

Medical Treatment for Cervical Cancer

Treatment for precancerous lesions differs from that of invasive cervical cancer.

For Precancerous lesions:

  • If you have a low-grade lesion (CIN I, as detected by a Pap smear), you may not need further treatment, especially if the abnormal area was completely removed during biopsy. You should have regular Pap smears and pelvic exams, as scheduled by your doctor.

 

  • When a precancerous lesion requires treatment, LEEP conization, cold knife conization, cryosurgery (freezing), cauterization (burning, also called diathermy), or laser surgery may be used to destroy the abnormal area while minimizing damage to nearby healthy tissue.

 

  • A hysterectomy for precancerous changes can be done, particularly if abnormal cells are found inside the opening of the cervix or you have severe or recurring dysplasia. This surgery is more likely to be done if you do not plan to have children in the future.

 

  • Treatment for precancerous lesions may cause cramping or other pain, bleeding, or a watery vaginal discharge.

 

  • Cryocautery may be used in some cases. In this procedure, a steel instrument is cooled to subzero temperatures by immersion in liquid nitrogen or a similar liquid. This ultracooled instrument is then applied to the surface of the cervix, freezing cells. They eventually die and are sloughed off, to be replaced by new cervical cells.

 

  • Tissue may also be removed by laser ablation. In this procedure, a laser beam is applied to either specific areas of cervical tissue or a whole layer of tissue at the surface of the cervix. The laser destroys these cells, leaving healthy cells in their place.

 

  • The success of cryocautery or laser ablation procedures is determined by a follow-up exam and Pap smear. Neither procedure is used to obtain tissue samples for evaluation; they only destroy the abnormal tissue. Therefore, the margins or edges cannot be inspected to make sure the cancer has not spread.

For Invasive cancer:

  • The most widely used treatments for invasive cervical cancer are surgery and radiation therapy. Chemotherapy or biological therapy also is sometimes used.

 

  • If the disease has spread into the uterus, hysterectomy — removal of the uterus and cervix — is usually necessary. Sometimes, the ovaries and fallopian tubes also are removed. In addition, lymph nodes near the uterus may be removed to check for spread of the cancer. Hysterectomy is also sometimes done to prevent spread of the cancer.

REFERENCES

  1. http://cebp.aacrjournals.org/content/21/9/1434
  2. https://www.cancer.org/cancer/cervical-cancer/about/what-is-cervical-cancer.html
  3. https://www.jostrust.org.uk/about-cervical-cancer/cervical-cancer/types-and-stages-cervical-cancer
  4. https://www.google.com.ng/search?q=webmd+cervical+cancer&oq=webmd++ervical+&aqs=chrome.1.69i57j0l5.11878j0j7&sourceid=chrome&ie=UTF-8

TOGETHER WE CAN FIGHT CANCER.

Otoighale Mercy-Mary.

Chukukere, Chidimma.

LNA Media Team

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leadnurseafrica

Lead Nurse Africa is a Pan-African nursing organization dedicated to public health promotion and professional development.

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