Cervical cancer is the fourth most common cancer among women worldwide. In India, where it is the second most common, it afflicts 1,27,356 women every year. More women in India than anywhere else are likely to die of cervical cancer, as per the Indian Council of Medical Research.
What it is: Cancer of the cervix, the lower part of the uterus connecting to the vagina. It occurs when cells in the cervix grow uncontrollably, often due to long-lasting infection with the human papillomavirus (HPV).
Risk factors: The most significant is HPV infection which causes nearly all cases of cervical cancer. Women who become sexually active at a young age, especially before 18, or have multiple sexual partners are at higher risk for HPV infection. Smoking can double the risk of developing cervical cancer as can having a weakened immune system. Additionally, women who have had multiple pregnancies or use oral contraceptives for many years may face increased risks.
Symptoms: Very few in the initial stages, which makes regular screenings important. When symptoms appear, they may include abnormal vaginal bleeding, such as bleeding between periods, after sex, or after menopause. Women might also experience unusual vaginal discharge. In more advanced stages, symptoms may include abdominal pain, fatigue, and even swelling in the legs.
How India compares with the west: India sees 17.7 cases each year per 1,00,000 women, while the rates in countries like the US are much lower (6.3 per 1,00,000 women). The median age at diagnosis is also higher in India, often leading to less favourable treatment outcomes.
Diagnosis: Through screening tests like the Pap test and the HPV test. The Pap test checks for precancers (cell changes on the cervix) that might become cervical cancer if not treated appropriately. The HPV test looks for the virus that can cause these cell changes. If these tests show abnormal results, then colposcopy is performed using a magnifying device to get a closer look at your cervix for abnormal areas. If necessary, a biopsy may be taken during this procedure to check for cancer cells.
The Pap smear routine: Start getting Pap smears at age 21 and repeat them every three years if the results are normal. From age 30 to 65, you can choose to get a Pap smear every three years or combine it with an HPV test every five years. Sexual activity or motherhood status doesn’t change these guidelines. If you've had a hysterectomy (removal of the cervix), you may not need Pap smears.
HPV vaccination: Protects against HPV, a common virus that can cause cervical cancer and other cancers. The Center for Disease Control and Prevention (CDC) recommends the HPV vaccine for boys and girls starting at age 11 or 12, though it can be given as early as age 9. Teens and young adults up to age 26 can also get vaccinated if they miss it. For adults aged 27-45, vaccination may be considered after consulting a doctor.
Dr Divyesh N. Panchal: is a professor in the Department of Obstetrics and Gynaecology at GCS Hospital, Ahmedabad. He is a member of the Social Welfare & Aao Gaon Chale Committee of the Ahmedabad Medical Association.
Prevention: The most effective prevention step is the HPV vaccination. Regular screenings like Pap tests are also crucial.
Lifestyle changes: Practice safe sex by using condoms. Limit the number of sexual partners. Avoiding smoking. Maintain a healthy diet rich in fruits and vegetables.
Pollution as a risk factor: Research shows that air pollution can contribute to the development of this disease. Exposure to various air pollutants, particularly from traffic, can increase the likelihood of developing cervical precancerous lesions and, ultimately, cervical cancer. Women living in areas with high levels of nitrogen oxides (NOx), which are emitted from vehicles, have been found to have a higher risk of cervical cancer. Passive smoking has also been linked to an increased risk of this cancer.
Stages of cervical cancer:
Stage 1: The cancer may be tiny or apparent, and it only affects the cervix.
Stage 2: The tumour extends to the upper vagina or tissues around the uterus but not the pelvic wall, passing beyond the cervix.
Stage 3: Cancer spreads to the pelvic wall, lower vagina, or adjacent lymph nodes, perhaps leading to kidney problems.
Stage 4: The cancer spreads to distant organs such as the liver, lungs, bladder, or rectum.
Initial treatment protocol: Depends on how far the cancer has spread. For early-stage cervical cancer (like stage IA), a cone biopsy is often the first choice if the patient wants to retain the ability to have children. If the biopsy shows no cancer at the edges, close monitoring may be enough. For those who do not wish to maintain fertility, options include radical hysterectomy, where the entire cervix is removed, along with surrounding tissues and lymph nodes. In some cases, radiation therapy may also be recommended. For more advanced stages, treatments often involve chemotherapy combined with radiation therapy. Overall, the treatment plan is tailored based on the patient's specific situation and preferences.
Impact on fertility: Some treatments, like surgery to remove the cervix and uterus, make it impossible to carry a pregnancy. Radiation and chemotherapy can cause infertility. Cone biopsy or trachelectomy (removal of the cervix while leaving the uterus intact) are options for early-stage treatment that preserve fertility. Modern advancements like fluorescent imaging-guided surgery help in precise treatment preserving fertility.
The risk for postmenopausal women: Studies show that while the incidence of cervical cancer is highest between ages 40-49, it remains significant in women aged 65 and older, with mortality rates peaking in those aged 80-84. Women over 65 suffer increased cervical cancer-related deaths due to lack of regular screenings. Additionally, older women face a higher risk of late-stage diagnosis, as symptoms can be overlooked or mistaken for postmenopausal changes.
Age and cancer screening: The risk of chronic HPV infections rises with age. Screening regularly lowers the risk of advanced cervical cancer, which is more difficult to cure.
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Biopsy versus Pap smear: The smear is a screening procedure which gathers cervical cells to look for abnormalities. It finds precancerous or worrisome alterations but does not confirm cancer. As a diagnostic process, a biopsy involves removing a small piece of cervical tissue and examining it under a microscope to confirm the presence of cancer. A Pap smear is a non-invasive test used in routine gynaecological examinations, but if abnormal cells are detected, a biopsy may be required to help clinicians assess the existence and severity of cervical cancer.
Treatment options: The patient's health and the stage determine the treatment options. Surgery is used in early stages. In advanced situations, radiation therapy is frequently needed, sometimes in conjunction with chemotherapy. For situations that are advanced or recurrent, targeted therapy and immunotherapy are new alternatives. The treatment needs to be customised based on variables like cancer spread, fertility preservation, and general wellness.
Kinds of surgery: A cone biopsy removes a small portion of the cervix in localised cases. If the condition is more severe, a hysterectomy (removal of the uterus) is often performed to prevent recurrence. In some cases, a radical hysterectomy (removal of the cervix, uterus, and surrounding tissues) is necessary. For cases where the cancer has spread further, pelvic exenteration (removal of pelvic organs) may be considered. In advanced cases, surgery is typically combined with other therapies.
The chances of recurrence: Depend on factors like the stage at diagnosis, treatment effectiveness, and overall health. Recurrence typically occurs within the first two to three years after treatment. Regular follow-ups, including imaging scans, HPV tests, and Pap smears, help detect recurrence early.
Sexual Health during and after treatment: Cervical cancer treatment can impact libido, cause vaginal dryness, pain during sex, and impact emotional wellbeing. Vaginal moisturisers and lubricants can help reduce dryness. Vaginal dilators and pelvic floor therapy can prevent vaginal narrowing. Addressing emotional concerns through sex therapy, psychotherapy, and open communication with a partner is crucial. If hormonal changes affect libido, hormone therapy may be an option.
Immunotherapy: Drugs like pembrolizumab (Keytruda) help the immune system recognise and fight cancer cells. Immunotherapy may be combined with targeted therapy or chemotherapy for better outcomes. It is not effective for all patients. Possible side effects include fatigue, skin rashes, and inflammation of the liver or lungs.
HPV testing and men: There is no standard HPV test for men, as HPV infections often cause no symptoms. However, the HPV vaccine protects against high-risk strains that cause cervical, throat, anal, and penile cancers. The vaccine is recommended for boys and men aged 9 to 26 and can be given up to age 45 in some cases. Men with symptoms like genital warts should consult a doctor. Safe sex practices, including condom use, help reduce transmission.
Know this too: Cervical cancer is not contagious but the HPV, which is a major cause of cervical cancer, can be transmitted through sexual contact. While there is a lowered risk for women who are not sexually active, there are other possible causative factors so regular screenings are advised. While not hereditary, genetic factors can influence susceptibility to HPV-related cancers. Screenings are a must because early-stage cancers show no symptoms.
Cervical cancer treatment can impact libido, cause vaginal dryness, pain during sex, and impact emotional wellbeing.