Cervical cancer is one of the most common cancers among women worldwide. The burden of disease is largely felt in the developing world due to suboptimal prevention strategies. It is largely caused by an infection of the Human Papillomavirus (HPV). There are about a hundred different subtypes of HPV but not all of them are oncogenic (cancer causing).
Exposure to HPV occurs due to sexual activity, however in a vast majority of women, this is a self-limiting infection, without symptoms or consequence. In others, the infection may persist leading to changes in the cells of the cervix which if not detected in time, will become cancerous.
High-risk subtypes of HPV that commonly cause cervical cancer are HPV 16 and 18, others include 31, 33, 45, 52 and 58.
The major risk factors for cervical cancer include:
- Early sexual intercourse (<17 years of age) and multiple sexual partners (>3 partners), this increases the risk of sexually transmitted infections and cervical cancer.
- Smoking.
- HIV infection, which increases the risk of development of cervical cancer among women.
- A poor immune system.
- The long-term use of the combined oral contraceptive pill (10 years or more).
- Low socioeconomic status.
- Multiparity (>7 child deliveries).
Screening And Vaccinations Against HPV
Cervical cancer can be prevented by two major public health efforts: pap smears for screening and vaccinations against HPV. Both these public health strategies are widely available but uptake in the developing world is somewhat limited due to lack of education, low socio-economic status, and other factors.
In Malaysia, a national cervical screening programme has been in place since 1969, and free pap smears made available in all government health facilities; however, the coverage rate still falls short of the level needed to prevent disease. Screening to a large extent remains opportunistic.
The vaccine against HPV is an effective one and it is part of the National Vaccination Programme in Malaysia since 2010, with all schoolgirls being vaccinated at the age of 13; reports indicate coverage in the excess of 80 per cent in Malaysia at present.
The vaccine is an indispensable method of prevention in countries like ours where uptake of cervical screening remains patchy.
Early cervical cancer is essentially asymptomatic and is usually picked up during a routine gynaecological examination and pap smear screening. In Malaysia, all sexually active women between the age of 30 and 65 years old are advised to undergo pap smears every three years.
Women who are less than 30 but sexually active are encouraged to undergo screening as well. This is a painless procedure that entails examination of cervical cells (obtained during a gynaecological checkup) under a microscope to look for early changes that may predict cancer.
There are also newer tests available to also detect oncogenic HPV subtypes for closer surveillance. An abnormal pap smear result is usually followed by a procedure known as colposcopy which allows a doctor to look at the cells of the cervix and biopsy abnormal areas to confirm disease or exclude disease. This is a day care procedure in most hospitals.
Symptoms Of Cervical Cancer
Symptomatic disease is essentially an indication of a more advanced disease stage and may present with:
- A tumour in the cervix.
- Watery, bloodstained discharge that is malodorous.
- Bleeding after sexual intercourse.
- Heavy and irregular menstrual loss.
- Difficulty in passing urine and/or haematuria (blood in the urine).
- Diarrhoea and/or blood in faecal matter.
- Dull abdominal and pelvic pain.
- Swelling of lower limbs.
Advanced disease may also present with loss of appetite and loss of weight, and a general feeling of unwellness.
When a suspicious mass is felt in the cervix, a biopsy is usually taken to exclude cervical cancer and staging of the disease is carried out to determine the extent of the disease. The disease is broadly divided into four stages, with Stage 1 indicating early disease located in the cervix alone and Stage 4 with widespread disease in distant organs (metastasis).
Treatments For Cervical Cancer
Staging is a surgical procedure undertaken in the operating theatre and is usually also combined with x- ray and other imaging studies of the urinary tract, pelvis, and bowel to predict extent of the diseases and plan treatments.
Surgical procedures for early diseases include:
- Cervical cryosurgery.
- Large Loop Excision of the Transformation Zone (LLETZ).
- Laser excision Cone biopsy.
- Hysterectomy (removal of the uterus).
For more severe disease, the patient may be advised to undergo a radical hysterectomy with removal of pelvic lymph nodes.
Other modes of treatment include radiotherapy and chemotherapy, which may be an adjunct to surgical management or used in isolation in advanced disease.
The exact treatment plan will be decided in consultation with a gynaecological oncologist.
A diagnosis of any type of cancer is usually associated with a risk of death and disability, it is the same with cervical cancer and outcomes are better when the disease is diagnosed early, with 5-year survival rates exceeding 90 percent for early disease. In advanced disease that has spread, the survival rates are poorer at about 40 to 50 percent.
Recovery From Cervical Cancer
Once a diagnosis of cervical cancer is made and treatment is completed, a patient will be followed up for recurrent disease which is usually lifelong. The longer the disease-free interval, the better the prognosis.
As a patient recovers there will be good and bad days with concerns about daily activity which should be taken a day at a time with support.
Of concern will be resumption of sexual activity as well, which may be affected due to the disease as well as the effects of therapy.
These will need to be discussed with the partner with the assistance of the attending doctor and counsellor to allay anxiety and move to as normal a situation as possible.
In younger women, fertility issues may need to be discussed if there is a want for more children to complete the family.
This is another complex area and may involve uterine sparing surgery, ovum (egg) harvesting prior to cancer treatment, adoption and perhaps surrogacy if allowed by the law.
Assoc Prof Dr Ganesh Ramachandran is the Head of School, School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University. Dr Khine Pwint Phyu is a senior lecturer in obstetrics and gynaecology at the School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of Ova.
