Cervical cancer

Types Of Cervical Cancer

Cervical cancers and cervical pre-cancers are classified based on their appearance on a microscope. They are most commonly of two types: 

Squamous cell carcinoma

It is the most common type (80-90%) that originates from the outer cervical cells, typically in the transformation zone where outer and inner cells meet.

Adenocarcinomas

This is the other type (10% to 20%) that develops from the mucus-producing gland cells of the inner cells of the cervix (endocervix).

Note: Less commonly, cervical cancers have features of both squamous cell carcinomas and adenocarcinomas and are called adenosquamous carcinomas or mixed carcinomas.

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Symptoms Of Cervical Cancer

Cervical cancer symptoms are usually mild in the early stages and can go unnoticed. Symptoms according to the stage of cancer include:

Early or stage 1 cervical cancer

Early-stage cervical cancer may not cause symptoms, but signs of stage 1 may include:

• Watery or bloody vaginal discharge 

• Foul odor in the vaginal discharge

• Vaginal bleeding after sexual intercourse

• Bleeding in between menstrual periods

• Longer and heavier menstrual periods

• Bleeding post menopause

• Discomfort during sexual intercourse

Advanced cervical cancer

If there is a spread of cancer (metastasis) to nearby tissues or organs, symptoms may include:

• Blood in urine

• Diarrhea

• Fatigue

• Weight loss

• Loss of appetite

• A general feeling of being ill

• Dull and aching pain in the back

• Swelling in the legs

• Pelvic/abdominal pain

• Difficulty or pain during urination 

• Pain or bleeding from your rectum while passing the stool

Note: It can take almost 20 years for the initial lesion caused by sexually transmitted HPV to develop into an invasive form of cervical cancer. 

Learn what the experts have to say about cervical cancer.
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Causes Of Cervical Cancer

• Almost all cervical cancers are caused by sexually transmitted human papillomavirus (HPV). 

• The human papillomavirus (HPV), which also causes genital warts, has over 1,000 strains, with HPV-16 and HPV-18 being the most common causes of cervical cancer.

• HPV causes cancer by its proteins E6 and E7 disrupting key tumor suppressor genes like P53 and retinoblastoma and altering DNA.

• Most people will get HPV at some point in their lives and not realize it as the body fights against the infection. 

• However, if the body fails to fight this infection, it can cause the cells of your cervix to change to cancerous cells. HPV can spread from the following:
  
  - Any direct skin-to-skin contact with the genitals 
  - Vaginal, anal, or oral sex
  - Sharing sex toys

Risk Factors For Cervical Cancer

Several risk factors for cervical cancer are linked to exposure to HPV which include:

1. Human immunodeficiency virus (HIV) infections

• According to studies the risk of developing an infection from high-risk HPV types is higher in women with HIV. 

2. Multiple sexual partners

• Many studies have suggested that women with multiple sexual partners are at high risk for HPV acquisition and cervical cancer. 

• Multiple sexual partners of the spouse can also be an additional risk factor.

3. Excessive use of oral contraceptives

• Oral contraceptive (OC) pills are known to be a risk factor for cervical cancer. 

• It has been reported in a study that the use of OC for 5 years or more can double the risk of cancer. 

4. Smoking

• Smoking increases the chance of developing precancerous lesions of the cervix (called moderate or severe dysplasia) and increases the chance of developing cervical cancer. 

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Smoking and HPV infections cause not just cervical cancer, but also the cancer of head and neck.
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5. Hygiene patterns

• Not using a sanitary napkin

• Not maintaining vaginal hygiene

• Not taking special care in cleaning their genitals when washing

6. Weak immune system

• Having a weakened immune system caused by immunosuppression increases the risk of HPV infection and cervical cancer. 

Diagnosis Of Cervical Cancer

Early stages of cervical cancer don't usually involve symptoms and are hard to detect. The International Federation of Gynecology and Obstetrics (FIGO) classified cervical cancer stages into the following:

Stage 0: Also known as carcinoma in situ, it is the presence of abnormal cells in the innermost lining of the cervix.

Stage I: Invasive form of cancer that is only confined to the cervix.

• Stage Ia cervical carcinoma: Preclinical invasive carcinoma that can be diagnosed only by means of microscopy.
• Stage Ib cervical carcinoma: Clinically visible lesion that is confined to the cervix uteri.
  - Stage Ib1: Primary tumor not greater than 4.0 cm in diameter.
  - Stage Ib2: Primary tumor greater than 4.0 cm in diameter.

Stage II: The locally limited spread of cancer beyond the uterus but not to the pelvic sidewall or the lower third of the vagina.

• Stage IIa cervical carcinoma: Spread into the upper two-thirds of the vagina without parametrial (the fat and connective tissue that surrounds the uterus) invasion.
• Stage IIb cervical carcinoma: Extension into the parametrium but not into the pelvic sidewall.

Stage III: Cancerous spread to the pelvic sidewall or the lower third of the vagina, and/or hydronephrosis or a non-functioning kidney that is incident to invasion of the ureter.

• Stage IIIa cervical carcinoma: Extension into lower one-third of the vagina, without spread to the pelvic sidewall.
• Stage IIIb cervical carcinoma: Extension into the pelvic sidewall and/or invasion of the ureter, with the latter resulting in a non-functioning kidney or hydronephrosis.

Stage IV: Cancerous spread beyond the true pelvis or into the mucosa of the bladder or rectum.

• Stage IVa cervical carcinoma: Extension of the tumor into the mucosa of the bladder or rectum.
• Stage IVb cervical carcinoma: Spread of the tumor beyond the true pelvis and/or by metastasis into distant organs.

Finding abnormal cells during cervical cancer screenings is the best way to avoid cervical cancer. Cervical cancer diagnosis requires the following:

1. A physical exam and complete medical history

• Examining the whole body to check general signs of health, including checking for any signs of disease, like lumps or anything unusual. 
• Past medical history, individual’s health habits, and prior illnesses and treatments will also be taken.

2. Pelvic exam

• An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum is done. 
• A speculum (tool doctors use to gently open the vagina for internal examination) is inserted into the vagina to look for signs of disease. 

3. Traditional pap smear

• A pap smear, also called a pap test, is a procedure to test for cervical cancer in women. It involves collecting cells from your cervix.
  
  

4. Liquid-based cytology (LBC) 

• Liquid-based cytology (LBC) is a new method of preparing cervical samples for cytological examination and unlike the conventional 'smear' preparation.

• It involves making a suspension of cells from the sample and this is used to produce a thin layer of cells on a slide. 

5. Visual Inspection 

• Visual inspection with acetic acid (VIA) is a visualization of a woman's cervix to detect precursors of cervical cancer after the application of acetic acid (ordinary table vinegar) on her cervix. 

6. HPV testing

• The HPV test is a screening test for cervical cancer.

• It doesn't confirm if an individual has cancer, instead, the test detects the presence of HPV, the virus that causes cervical cancer, in the system. 

7. Computerized screening

• Computer-assisted image analysis and artificial intelligence have been introduced as a means of improving the sensitivity of the Pap smear. 

• Artificial intelligence (AI) has also shown promising results in screening and examination based on image pattern recognition. 

8. Endocervical curettage

• This is a procedure to collect cells or tissue from the cervical canal using a curette (spoon-shaped instrument). 

• Tissue samples are taken and checked under a microscope for any signs of cancer. 

9. Colposcopy

• A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas. 

• Tissue samples may be taken using a curette (spoon-shaped instrument) or a brush and checked under a microscope for signs of disease.

10. Biopsy

• This is done if the pap smear shows any abnormal cells. 

• A sample of tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of cancer.

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11. Imaging 

These tests help doctors find out where the cancer is located and whether it has spread to other parts of the body. They include:

• Computed tomography (CT) scan: It involves taking pictures of the cervix at specific times after the intravenous (IV) injection of contrast medium to find out exactly where the tumor is in relation to nearby organs and blood vessels. 
  
  
• Positron emission tomography (PET) scan or PET-CT scan: A PET scan is usually combined with a CT scan or MRI scan to produce images of the inside of the body. The combination provides a more complete picture of the area being evaluated.
  
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Prevention Of Cervical Cancer

There are more than 100 kinds of HPV and about a dozen of them have been shown to lead to cancer. The two most important things to prevent cervical cancer are to get the HPV vaccine and to get tested regularly according to American Cancer Society (ACS) guidelines. These include:

1. Undergoing cervical screening

• Early detection of the types of HPV that can cause cancer is key to preventing cervical cancer. 

• A well-proven way to prevent cervical cancer is to have screening tests.

2. Getting the HPV vaccine

• The HPV vaccine can help prevent HPV infection by protecting against HPV. 

• These vaccines help prevent pre-cancers and cancers of the cervix. 

• Some HPV vaccines are also approved to help prevent other types of cancers and anal and genital warts.

Note: India accounts for around 16% of the total deaths caused by cervical cancer across the world. And it can be prevented with a vaccine. Learn more about Vaccine To Prevent Cervical Cancer: Age, Types, Schedule & More.

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3. Limiting exposure to HPV

• Encouraging the partners to talk with a doctor or nurse about the HPV vaccine.

• Not having sex when there are visible warts

• Limiting the number of sex partners

• Avoiding sex with people who have had many other sex partners

4. Not having unprotected sex

• Some methods used to prevent sexually transmitted diseases (STDs) decrease the risk of HPV infection. 

• The use of a barrier method of birth control, such as a condom, and dental dams during oral, anal, and vaginal sex can help protect against HPV infection. 

Using condoms significantly reduces the risk of HPV (human papillomavirus) infections by providing a barrier that minimizes skin-to-skin contact during sexual activity. CTA: Prioritize your health—choose condoms for protection and peace of mind.Buy Here

5. Maintaining a healthy lifestyle

• These may include eating fruits and vegetables, exercising, quitting smoking, or taking certain medicines, vitamins, minerals, or food supplements.

Doctor To Visit

Every kind of cancer requires comprehensive care that consists of a group of doctors. Doctors who take care of patients with cervical cancer and help in diagnosing and formulating a treatment plan are:

• Gynecologist

• Gynecologic oncologist

• Radiation oncologist

• Medical oncologist

A gynecologist specializes in female reproductive health. 

A gynecologic oncologist specializes in cancers of the female reproductive system and can perform surgery and prescribe chemotherapy and other medicines. 

A radiation oncologist is a doctor who uses radiation to treat cancer.

A medical oncologist uses chemotherapy and other medicines to treat cancer.

What to ask your doctor?

• What type of cervical cancer do I have?

• Has my cancer spread outside the cervix?

• What is the stage of my cancer and what does that mean?

• Will I need other tests before we can decide on treatment?

• Do I need to see any other doctors or health professionals?

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Treatment Of Cervical Cancer

Different types of treatment are available for patients with cervical cancer. They include:

1. Surgical procedures

• Conization: A procedure in which a cone-shaped piece of abnormal tissue is removed from the cervix. 

• Hysterectomy: A hysterectomy is a surgical procedure to remove the womb (uterus). A hysterectomy can be:

  • Simple hysterectomy: It is the removal of the uterus and cervix. 

  • Radical hysterectomy: It is the removal of the uterus, cervix, upper vagina, and the tissue around the cervix. A radical hysterectomy also includes the removal of the surrounding lymph nodes.

• Loop electrosurgical excision procedure (LEEP): This procedure uses a wire loop heated by an electric current to remove cells and tissue in the cervix and vagina. It is used as part of the diagnosis and treatment for abnormal or cancerous conditions.

• Exenteration: This surgery is done if cancer has come back within the pelvis (the lowest part of your tummy, between your hips). This procedure removes the cervix, uterus, and ovaries.

• Radical trachelectomy: It is a surgery to remove the cervix, nearby tissue and lymph nodes, and the upper part of the vagina. It can be used to treat women with early-stage cervical cancer to preserve their fertility. After the cervix is removed, the uterus is attached to the remaining part of the vagina.

• Bilateral salpingo-oophorectomy: This is a surgical procedure to remove both the ovaries and fallopian tubes. It is done at the same time as a hysterectomy.

2. Radiation therapy

Uses high-energy X-rays or other particles to destroy cancer cells. Radiation therapy may be given alone, before surgery, or instead of surgery to shrink the tumor. The types of radiation therapy include:

• External-beam radiation therapy: The most common type of radiation in which the radiation is given from a machine outside the body. 

• Internal-beam radiation therapy: When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. Brachytherapy involves the application of a radioactive source near the tumor. 

Note: For the early stages of cervical cancer, a combination of radiation therapy and low-dose weekly chemotherapy is often used. This is done to increase the effectiveness of the radiation treatment. 

3. Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. The chemo drugs most often used include:

• Cisplatin
• Carboplatin
• Paclitaxel (Taxol)
• Topotecan

4. Targeted therapy

In this treatment, specific genes, proteins, or the tissue environment that contributes to cancer growth and survival are targeted. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.

For recurrent or metastasized cervical cancer platinum-based chemotherapy combined with the targeted therapy is used. Targeted therapy uses the following:

• Bevacizumab (Avastin)
• Bevacizumab-awwb (Mvasi)
• Bevacizumab-bvzr (Zirabev)
• Tisotumab vedotin (HuMax-TF)
  

5. Immunotherapy

• This therapy uses the body's natural defenses to fight cancer by improving your immune system’s ability to attack cancer cells.

• The immune checkpoint inhibitor pembrolizumab (Keytruda) is used to treat cervical cancer that has recurred or metastasized during or after treatment with chemotherapy. 

• It may also be used with chemotherapy with or without bevacizumab in people with recurrent or metastatic cervical cancer.

Home-care For Cervical Cancer

The news of cervical cancer can be devastating. Cancer not only affects the body but has a serious effect on the mind as well. Some of the things that the patients can do at home that can help manage the symptoms of treatment include:

• Taking enough rest post any surgical procedure

• Being physically active

• Quitting smoking

• Getting emotional support from loved ones

• Following all the instructions given by doctors

• Eating a well-balanced and nutritious diet

• Adding nutritional supplements to the diet

• Taking to a counsellor

• Adopting a healthy behaviour

• Avoiding sex for 6-8 weeks after hysterectomy

Note: Cervical cancer diagnosis can lead to chronic stress. With so much to take care of, one often finds it hard to cope with situations that are beyond control. Read about effective ways to manage chronic stress.

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Complications Of Cervical Cancer

Cervical cancer complications are seen in advanced disease and associated treatments and are similar to other cancers. They may include:

• Kidney failure: Kidney involvement typically occurs in the more advanced stages of cervical cancer. Kidney failure in cervical cancer can often be associated with blockage of the ureters.

• Hydronephrosis: This is the swelling of a kidney due to a build-up of urine. It represents an advanced disease in patients with cervical cancer, as it indicates the involvement of the parametria.

• Pain: It is seen when cancer progresses and spreads to nearby tissues and organs. The individual may experience pain in the pelvis or have issues urinating.

• Lymphedema: It refers to tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system. Lymphedema is usually seen as a result of treatment involving pelvic radiotherapy or lymph node removal. 

• Blood clots: Like any other cancer, cervical cancer can make the blood thicker leading to the formation of blood clots. Large cervical tumors can also put pressure on the veins in the leg, helping clots to form. 

• Fistulas: A fistula is an abnormal connection between two body parts, such as an organ or blood vessel, and another structure. 

• Orbital apex syndrome (OAS) and blindness: OAS, a rare condition linked to malignant mixed Müllerian tumors (<5% of uterine cancers), involves optic nerve damage when cancer spreads to the eye.

Prevention is better than cure! HPV vaccine can be your shield against cervical cancer. 
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Alternative Therapies For Cervical Cancer

When exploring alternative treatments for cervical cancer, always consult your medical team, as some may conflict with your treatment plan. Common alternatives include:

1. Naturotherapy

A holistic approach using plant-based nutrients can support cervical cancer treatment. While not a replacement for conventional therapy, it may enhance chemotherapy and radiotherapy effectiveness. Helpful herbs include:

• Curcumin or turmeric (Haldi)
• Ginger root (Adrak Ki Jadh)
• Holy basil (Tulsi)
• Green tea
• Grapes (Angoor)
• Broccoli
• Banana (Kela)
• Cabbage.

2. Homeopathy

• Homeopathy is considered a complementary approach that may help manage symptoms and improve overall well-being in cervical cancer patients. 

• It should always be used alongside conventional treatments under medical guidance.

3. Acupuncture

• One of the most distressing and intractable conditions in patients with cancer is pain. 

• Acupuncture is recommended for patients to control cancer pain. 

• Previous studies have reported that it not only has beneficial efficacy for cancer pain management but also almost has no adverse events for patients with cancer pain.

• However, more research is required to specifically explore the effectiveness of acupuncture at pain acupoints for cervical cancer pain.

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Living With Cervical Cancer

Cancer impacts physical, emotional, social, and financial well-being, making it a challenge for patients and families. For some, cancer may persist, requiring ongoing care. Here are tips to cope:

1. Give importance to palliative care

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Palliative treatments vary widely and often include: 

• Medication to relieve the symptoms

• Nutritional changes

• Relaxation techniques

• Emotional and spiritual support

• Encouraging the patient to do things they love.

2. Follow up regularly

• Most doctors recommend that women treated for cervical cancer keep getting regular Pap tests no matter how they were treated (surgery or radiation).

• Survivors of cervical cancer should be vigilant for early detection of any other cancer, such as breast, lung, and colorectal cancer. 

• Imaging tests may be done if the signs or symptoms of cancer come back.

3. Manage the physical symptoms of advanced cancer

• Advanced cervical cancer means cancer that has spread to other areas of your body, such as the liver or lungs. Unfortunately, advanced cancer can't usually be cured. 

• However, treatment can often control cancer and relieve symptoms. 
  
  

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4. Focus on emotional and mental wellbeing

Fear and anxiety related to cancer or the ongoing treatment can be managed by:

• Talking about advanced cancer

• Sharing feelings with close family members and friends

• Getting all the information needed to go about with the treatment

• Understanding the physical limitations

• Managing the sexual relationship by talking to the partner

• Coping with practical issues like:

  • Financial expenses

  • Childcare

  • Work issues

5. Supervise the cost of cancer care

• Cancer treatment can be expensive and coping financially can become a source of stress and anxiety for patients and their families. 

• In addition to treatment costs, there might be extra unplanned expenses as well. This can stop many patients from continuing the treatment. 

• This can be managed by asking the social worker about benefits or grants, they can also help with the claiming process. 

Tips for caregivers

• Encouraging and providing mental support to the patient

• Understanding the course of treatment

• Helping the patient manage their symptoms and side effects

• Coordinating their medical appointments and giving medications on time

• Assisting the patient in maintaining personal care and hygiene

• Talking with empathy and a positive attitude toward the patient

• Helping the patients with household chores

• Handling insurance and billing issues for them.