Cervical cancer

Cervical cancer is one most common gynecological cancer occurring in women. It is also one of the most common cancers of women that can be detected and treated completely at precancerous stages.

In developing countries, it is the most common cancer which causes death, attributable to about 86%. It is observed in low and middle income countries. Primary stage surgery and chemotherapy are effective. Surgery also helps to reduce the death of patients of cervical cancer. Chemotherapy and Radiation is not useful for all patients. Radiation or chemotherapy of the 1523 patients, 179 patients give positive response and 1344 give negative response of allover about 88.6% negative to surgery.

Cervical cancer is the 13th most common cancer among U.S. women (American Cancer Society, 2000). An estimated 12,800 new cases were diagnosed in 2000 and an estimated 4,600 U.S. women died from the disease that same year. In the United States, racial and ethnic disparities in incidence and mortality from cervical cancer have been identified. For example, incidence is higher among Vietnamese and American Indians than among women of other racial and ethnic backgrounds, and higher among Hispanics than non-Hispanics. In India, cervical cancer is one of the leading malignancies among women, with about 130,000 new cases and 74,000 deaths every year" accounting for 30% of global cervical cancer mortality. India's cervical cancer age-standardized incidence rate (30.7 per 100,000) and age-standardized mortality rate (17.4 per 100,000) are the highest in South Central Asia.

Cancer can begin when a cell develops abnormally. Cancer can start almost anywhere in the human body. Cervical cancer begins in the surface tissue of the lower region of the female genitalia in the uterine cervix. There are two types of cells seen in the female genitalia: squamous cells and epithelial cells. Where they meet and overlap is collectively known as the transformation zone. This is where cancer cells most commonly manifest. The initial stage of cervical cancer is asymptomatic.

Cervical cancer is frequently observed in women in their mid-30s. The chance of developing this disease increases as the body ages. Regular cervical screening is an invaluable tool to combat this pernicious disease. Ignorance of or disregard toward HPV-and its link to cervical cancer has adversely affected a vast number of women; in particular, Hispanic, African American, Native American, and Alaskan Natives.

Many factors can compromise a host and contribute to the development of cervical cancer: HPV infection (predominantly HPV strains 16 and 18); cigarette smoking; immunosuppression (immunocompromised patients on medication); chlamydia infection (may be asymptomatic); fiber deficient diet (diet low in fruits and vegetables); oral contraceptives; intrauterine devices (IUDs); exposure to diethylstilbestrol (DES); and a family history of cervical cancer. Cervical cancer is usually asymptomatic until the cancer cells begin to invade the surrounding tissues. Symptoms may include atypical periods, pelvic pain, pain during sexual activity, vaginal discharge and oozing during sexual activity, and in the post menarche years. Women in their teens are susceptible to cervical cancer. Their reproductive systems are still immature, and they may be more sexually active and, thus, more exposed to infection. Poverty and ignorance are significant co-factors. Women in poverty or with low incomes cannot afford proper medical care or screening. Women living in rural areas can be negatively affected due, in some cases, to lack of education and community awareness.

Nearly all cases of cervical cancer can be attributed to infection with human papillomavirus (HPV). HPV types are categorized as low-risk or high- risk strains depending on their oncogenic potential. Low-risk strains of HPV may be asymptomatic or may cause anogenital warts, whereas high-risk strains are oncogenic. Over 99% of precancerous lesions (cervical dysplasia) and cervical carcinomas are caused by high-risk HPV infection. More than 200 strains of HPV have been identified, of which approximately 40 infect the anogenital region. 15-18 of these HPV strains have been classified as high-risk genotypes. Virtually all cervical neoplasias and cancers are attributable to high-risk HPV genotypes.

Pap test (Pap smear, smear test or cervical smear) is used to determine the presence of precancerous or cancerous cells; wherein, utilizing a speculum, cervical tissue is gently collected (by swab or brush) and subjected to microscopic evaluation. An abnormal Pap test may indicate the need for further investigation. (Although, it must be kept in mind that the Pap smear is not 100% reliable.)

Naked eye visual inspection is carried out after a Pap smear has demonstrated the presence of abnormal cells. A speculum is inserted into the vagina to inspect the cervix. An acetic acid solution of 5% (VIA) and/or of Lugol's iodine (VILI) is applied to make any precancerous lesions or early invasive cancer cells be visualized more clearly. If abnormal tissue is detected, a small portion of the tissue is removed from the surface (a biopsy) which is then sent to a pathologist for further evaluation.

Colposcopy utilizes a low-powered microscope to view the cervix and vagina so the doctor can locate any abnormalities, and biopsy the area. However, a biopsy can be performed without colposcopy.

Endocervical curettage (ECC) is a procedure in which the mucous membrane of the cervical canal is scraped using a spoon shaped surgical instrument called a curette. ECC is used to test for abnormal tissue, precancerous conditions or cervical cancer. Slight bleeding can occur due to this procedure.

Conization (cold knife conisation-CKC) is a technique wherein tissue is removed from the cervix in a cone shape for diagnostic or treatment purposes. Loop electrosurgical excision procedure (LEEP) utilizes an electrical current wire loop to separate the subject tissue from the cervix (also for diagnostic or treatment purposes).

The treatment for cervical cancer depends on the stage of malignancy. The gynaecologist and oncologist are the medical specialists that determine and oversee the treatment plan. Treatment options include surgery, pharmacotherapy, chemotherapy, radiation therapy, hyperthermia, cryotherapy and laser. Treatment options are based on the stage of the cancer, the type of cancer, the patient's age and the patient's desire to have children.

Acknowledging that procreation is fundamental to human existence, continual efforts at HPV vaccination, screening, early detection, and treatment must evolve to meet the WHO goal of cervical cancer elimination defined as an incidence of 4/100,000 as soon as possible.

The WHO plan calls for HPV vaccination by 2030 of 90% of the world's girls before age 15 years. All future generations must continue HPV vaccination at this coverage to maintain the 4/100,000 control goal,' without which increasing numbers of women will die of cervical cancer. HPV vaccination prevents type specific cervical intraepithelial neoplasia grade 3 (CIN 3) and induces neutralizing antibodies for at least 12 years. Current vaccine formulations still require cold chain storage and injection delivery, which present logistical problems that local health ministries must solve. Time-limited vaccine donations and reduced-cost programs have sustained vaccine supply in low- and middle-income countries. In-country HPV vaccine manufacturing may relieve the vaccine equity issue when these resources are no longer available. The next evolution of HPV vaccination ideally includes pan-protection regardless of HPV type, vaccination at a much earlier age, the use of a single dose, and a model of continued HPV boosters coincident with the time of screening, similar to tetanus prevention, over the next 100 years. Cervical cancer elimination needs HPV vaccination as its first step.

Published : Nov 20 2023