In the middle of a busy day I open my WhatsApp only to find a message informing me that one of my patients has passed away. Cervical cancer. To add salt to injury a video of a lively version of her dancing to some local beats in her better days accompanies the message. From the video I can see this was taken whilst she was on treatment but still full of energy. I am often asked if my type of work is depressing. No it is not. Sad sometimes, but not depressing. Despondency is for those who do not know what to do with a situation. I know exactly what to do with cancer so I make a resolution that in memory of my patient I will once again raise awareness on cervical cancer, how it can be prevented, detected early and treated. We never tire of teaching and allow me to teach by answering common questions.
What is the cervix?
The cervix is the neck of the womb being an entry point from the vagina. The whole internal female genitalia is lined with cells called the epithelium. The cell types of this epithelium change from a type called squamous cells along the vagina into columnar cells, which are glandular into the uterus. The area in which this change happens is called the transformation zone and this is where most cervical cancers arise.
What is cervical cancer?
Cervical cancer is the abnormal replication of cells in the cervix. These cells have the potential to migrate to other parts of the body such as bone, lung, liver and cause growths called metastasis, which can affect the function of these organs.
What causes cervical cancer?
The risk factors of cervical cancer are Human Papilloma Virus (HPV) and being exposed to diethylstilbestrol (DES) whilst in the mother’s womb. DES was used to prevent miscarriages before1970 but is not used now as it has been shown to increase risk of clear cell cervical cancer.
HPV on the other hand is a more likely cause of cervical cancer in our environment. It must be noted that an infection with HPV is not equal to cervical cancer and it can be cleared if an individual’s immunity is strong enough. However if HPV persists it can cause changes in the cell blueprint and turn cells into pre-cancer and eventually into cancerous lesions. Other factors that compound the HPV infection leading to cancer are giving birth to many children, smoking cigarettes, using oral contraceptives, immune suppressive conditions e.g. HIV, transplant related, being sexually active at a young age and having multiple sexual partners.
How can cervical cancer be prevented?
- Lifestyle choices: diet, exercise, no smoking, good sexual health practices etc.
- Primary prevention with vaccination against HPV high risk strains
- Secondary prevention by treating precancerous lesions which can be detected by a method called cervicography or colposcopy. Treatment methods of pre-cancer include LEEP (burning) and cryotherapy (freezing)
How can cervical cancer be caught early?
Screening allows us to catch a cervical cancer before it starts giving symptoms to the patient. The chances of cure are higher on a cancer caught by screening compared to a cancer caught after a patient has presented with prolonged symptoms.
The current gold standard for screening is the HPV DNA test. Pap smear is also a method that has been used successfully for years. Visual inspection with acetic acid (VIA) is a low cost method of screening that can be used in low resource environments.
What are the symptoms of cervical cancer?
Bleeding outside menstruation is a common symptom. Pain after sexual intercourse (dyspanuria) is an early symptom as well. Lower abdominal pain, weight loss, foul smelling discharge that can be watery or pus-like are other symptoms one may experience.
What are the treatment methods available for cervical cancer and what are their indications?
Surgeryalone can be used to treat early stage cervical cancer that is confined to the cervix and upper third of the vagina if it is 4 cm or less. This is the ideal scenario. In other poor resource environments where radiotherapy is not available, surgery is used to treat even more advanced disease. A range of surgical procedures can be employed including removal of only the neck of the uterus (trachelectomy) to some very big procedures where the uterus, part of the vagina, ovaries and lymph nodes are taken out together with the cancer (radical hysterectomy)
Radiotherapy and chemotherapy. When cervical cancer is more than 4 cm and/or has spread beyond the cervix into the tissues that surround the uterus called parametria, surgery is not the best option. Radiotherapy uses strong X-rays that kill cancer cells. Chemotherapy in this case potentiates the action of the radiotherapy to make it more effective. It also plays a small role in mopping up cancer cells that may have wandered off to other parts of the body. This treatment modality when used for radical (curative intent) in cervical cancer lasts for about 6 weeks. The patient must come into the hospital daily for treatment.
Radiotherapy can be used in cases where cure is not possible but symptoms need to be managed. It controls bleeding and pain.
Radiotherapy can be delivered by two methods: external beam and brachytherapy. External beam radiotherapy also known as teletherapy delivers radiation from a distant point as the patient lies on a treatment bed. Brachytherapy (brachy- means short) delivers radiotherapy at short range. The applicators are placed right next to the cancer.
Chemotherapy alone or with a targeted agent (Bevacizumab) can be used to treat disease that has spread beyond the uterus. It is usually given in cycles every 3-4 weeks to a maximum of 6 times.
Most patients experience side effects from treatment, which can be mitigated. This fact usually discourages patients to attempt radical treatment. However, this should not be the case, as the oncologist will not prescribe treatment for a patient where the risk outweighs the risk. And this brings me to the last part of the continuum of care, which is called ‘Best Supportive Care’ (BSC).When a patient’s condition is assessed as being too poorly to withstand potential side effects oncologists may decide the patient may benefit only by treatment of symptoms. This must not be confused with palliative care, which forms part of BSC but can be applied to both curative and non-curative patients.
This in a nutshell is cervical cancer.