The month of January is dedicated to raising awareness about Cervical cancer. Cervical cancer is themost common gynecological cancer and the fourth most common cancer in the world. According to a 2021 publication by the Indian Council of Medical Research – National Centre for Disease Informatics and Research (ICMR-NCDIR), in the North East region, cervical cancer in the second most common cancer in women. In Nagaland, cervical cancer is the most common cancer seen in women and the second most common cause of cancer related deaths in women in the State. However, the screening rates for cervical cancer in the state remain dismal (0.3% only). The theme for this year is “Learn, prevent and screen” and I hope to educate everyone about this disease and how women can get themselves screened for it.
Introduction and Risk factors
Cervix is the lower most part of the uterus. The most common cause for cervical cancer has been attributed to the Human Papilloma Virus (HPV). The most common strains of HPV implicated in causing cervical cancer are HPV 16 ad 18. HPV is also responsible for causing cancer at other sites like vagina, vulva, head and neck region (oropharynx) and anus. It can also cause anogenital warts, which are benign. The risk factors leading to cervical cancer include early age at marriage, having multiple children, having multiple sexual partners, unprotected sex, smoking and oral contraceptive pills.
Symptoms
The most common symptom that women present with is bleeding from the vagina. Since this is a cancer that most commonly occurs in the reproductive age group, the common symptoms that is noticed is heavy bleeding during menses, which is more than usual or inter-menstrual bleeding. Other symptoms can include passage of whitish discharge from the vagina, lower abdominal pain, flank pain, back pain, urinary complaints.
Screening
The two screening tests available for Cervical cancer are Pap smear and HPV DNA testing. HPV testing involves checking for the presence of 13 cancer-causing types of HPV in a collection of cells obtained from a swab of the cervix or vagina. HPV testing is approximately 90% accurate for detection of pre-cancer. Another screening test for cervical cancer is the Papanicolaou (Pap) test, which examines cervical cells for abnormalities and has an accuracy of 50% to 70% for detecting pre-cancer.
Cervical cancer screening is recommended at least every 5 years for women aged 21 to 65 years. From 21 to 29 years, Pap smear is recommended and from 30 years onwards, Pap smear along with HPV DNA testing is recommended. Women with a higher-than-average risk of cervical cancer (eg, those with prior abnormal cervical cells, pre-cancer, cervical cancer, or who are immunosuppressed) should be screened more frequently. Screening for cervical cancer can be stopped at age 65 years in women with:
- At least 3 consecutive negative Pap tests or 2 consecutive negative HPV DNA tests in the past 10 years, with the most recent in the previous 5 years
- No abnormal test results during the previous 10 years
- No history of cervical cancer
- No history of cervical precancer during the previous 25 years
- No immunosuppression (HIV, auto-immune disease, or using immunosuppressants like steroids for long time, etc)
Vaccination
Vaccination against HPV is likely to prevent more than 90% of cervical precancers and cancers. Guidelines recommend that all children aged 9 to 12 years receive 2 doses of HPV vaccine given 6 to 12 months apart. HPV vaccination is also recommended for individuals aged 13 to 26 years who were not previously vaccinated, with 3 doses of HPV vaccine given when vaccination begins at age 15 years or older. After 26 years, there is questionable benefit in taking the vaccine.
Diagnosis
Confirmation of a diagnosis for cancer is always done by a biopsy. Biopsy is taking a piece of tissue from the site of cancer and testing it under a microscope. Punch biopsy is usually taken from the cervix for confirmation. Imaging is done to confirm the stage of the disease. The most common imaging modalities used in ca cervix is CT scan or MRI.
Staging
Cancer usually consists of stages ranging from I to IV. Stage I is when the cancer is strictly confined to the cervix. Stage II is if it goes beyond uterus but not extended beyond the lower third of the vagina. Stage III is if the cancer involved the lower third of the vagina and/or extends to the pelvic wall and/or causes damage to the kidneys or has spread to the pelvis or para-aortic lymph nodes. Stage IV in ca cervix consists of Stage IV A and B. Stage IV A is if the cancer in the cervix involves the bladder or rectum. Stage IV B is when the cancer has spread from the cervix to the other parts of the body (lungs, liver, bones etc).
Treatment
Stage I is usually managed with surgery. This can include removing the cervix alone in women who wish to preserve their fertility in very early stages or removing the entire uterus along with the draining lymph nodes in those women with later stages and who have completed their families
Stage II & III- Here, both surgery and chemotherapy and radiation can be given. Surgery is usually done if in Stage II A and it is not bulky. Otherwise, radiation therapy is the treatment of choice along with chemotherapy.
Stage IV A- chances of cure decrease significantly. Mostly, chemo-irradiation is given. If it recurs/relapse, then an extensive surgery called “pelvic exeneteration” (removal of entire uterus, bladder, rectum) is done.
Stage IV B- This is the last stage and here,no curative option can be offered and intent of treatment remains palliative. The treatment options available are chemotherapy or immunotherapy. Radiation therapy can be given for palliative purposes for symptom relief (pain, bleeding etc).
Dr. Vishala Rose
Marie Varghese
Junior Consultant,
Dept of Radiotherapy,
Christian Institute of Health Sciences and Research
(CIHSR), Dimapur,
Nagaland 797115, India