Overview
In Western Europe, the treatment of cervical cancer is a success story. Cervical screening has led to many cases of Cervical Intraepithelial Neoplasia - (CIN) and cervical cancer being diagnosed early which in turn has led to simpler treatments and better results. However, those cases that do occur tend to be more aggressive, faster growing tumours.
In some parts of Eastern Europe cervical cancer rates have increased over the past 20 years.
The advent of an HPV screening programme should have a further dramatic impact on the incidence of cervical cancer in 30 to 40 years' time. If an effective vaccination programme could be introduced globally, cervical cancer could be eradicated.
Cancer of the cervix may affect women under 35 years old and is the second most common form of cancer in this age group (only breast cancer occurs more frequently).
Provided that cervical cancer is diagnosed in its early stages it can be treated effectively with surgery and radiotherapy.
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Key Figures
| Total number of new cancer cases in Europe (2006) |
3.2 million |
| Total number of cancer deaths in Europe (2006) |
1.7 million |
| Number of new cervical cancer cases in Europe (2002) |
59,931 |
| Number of cervical cancer deaths in Europe (2002) |
29,812 |
| Incidence rate of cervical cancer in Northern Europe (2001) |
8.8/100,000 per year |
| Mortality rate of patients with cervical cancer in Northern Europe (2003) |
2.8/100,000 per year |
Worldwide, cervical cancer is the fifth most deadly cancer in women.
It affects about 1 per 123 women each year and kills about 9 per 100,000 women per year (equivalent to 473,000 cases of cervical cancer and 253,500 deaths per year respectively).
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Cancer Types
There are two types of cervical cancer:
Some cervical cancers are very slow growing but others are more aggressive. The proportion of these aggressive tumours is rising.
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Causes of Cervical Cancer
A prominent cause of cervical cancer is infection with certain types of Human Papilloma Virus (HPV). The virus triggers alterations in the cells of the cervix. This alteration can lead to cervical intraepithelial neoplasia, which in turn can cause cancer.
15 types of HPV are classified as high-risk types for cervical cancer: types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 and 82.
Having many sexual partners creates a greater risk.
A poor immune response increases the chances of CIN developing into cervical cancer.
Smoking, poor diet, drugs used to treat other cancers and auto-immune and other infections (such as HIV) are all risk factors.
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Prevention of Cervical Cancer
Use of condoms reduces, but does not always prevent, transmission of HPV.
Awareness of the common symptoms listed below leads to earlier presentation, which generally provides better outcomes.
Screening detects early changes in cervical cells so that with treatment their development into cancer can be prevented.
Vaccination against HPV - even where a vaccination programme is in place, it will take years before all women at risk are protected.
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HPV Vaccination
Vaccines have now been developed against HPV. Different vaccines provide protection against different strains of the virus but no vaccines are yet available for all types of HPV virus.
Gardasil® provides immunity to HPV types 6, 11, 16 and 18, which are responsible for approximately 75% of all cervical cancers.
Cervarix® provides immunity to HPV types 16 and 18, which are responsible for approximately 70% of cervical cancer cases.
The vaccine is most effective in women who have not been exposed to HPV infection. Therefore, it is best given to females who have not been sexually active, which is why vaccination programmes are aimed at pre-teen and teenage girls (the UK National programme targets girls at the age of 12).
There is no evidence that the vaccine is of benefit in preventing infection in men.
Three injections are given over a 6 month period, and a booster may be required after an interval of some years.
Possible side effects include pain and swelling where the vaccination is given. Very rarely, allergic reactions may occur.
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Common Symptoms
Often there are no symptoms, but where there are they typically include:
- bleeding after sexual intercourse
- bleeding between menstrual periods
- bleeding after the menopause
- discomfort or pain during sex
- an unusual vaginal discharge
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Diagnostic Tests
Cervical Screening
Two forms of screening test are used:
- A sample of cells is taken from the cervix using a small spatula or brush and this is spread onto a slide for examination under the microscope.
- A sample can be taken using a brush to remove cells from the cervix and these cells are then preserved in a liquid before being examined under a microscope (liquid-based cytology).
Cervical smears should be taken in the middle of the menstrual cycle.
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Treatment
Treating Cervical Intraepithelial Neoplasia (CIN)
A colposcopy is a detailed examination of the cervix, which is often recommended if a cervical smear result is abnormal - the aim being to prevent CIN progressing to cervical cancer.
The colposcope is a specialised small camera used to examine the cervix. It can detect areas of CIN so that samples can be taken for examination under the microscope.
Various surgical treatments, such as freezing the affected areas (cryotherapy) or using lasers or a Loop Electrical Excision Procedure (LEEP) can be used to treat abnormal areas.
Treating Cervical Cancer
Successful treatment of cervical cancer requires a multidisciplinary team of health professionals, each with their own expertise. This will include gynaecologists, pathologists, medical oncologists, radiation oncologists, imaging specialists and their support teams.
Together, they analyse information about the exact type of cancer, how fast-growing the tumour is, and whether it has spread to other areas of the body. They will also consider the patient's general health and the patient's own preferences with regard to the treatment plan, which may include surgery, radiotherapy and chemotherapy.
Ultimately, the choice of treatment rests with the patient, based on the advice of all the specialists involved.
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Surgery
Surgery for cancer of the cervix is best conducted in specialist centres under the care of gynaecological oncologists.
There are a number of options for treatment including:
- Cone biopsy for cancers that are confined to the surface of the cervix.
- Trachelectomy - in which the cervix and the upper part of the vagina are removed, but the rest of the uterus is left in place. Pelvic lymph nodes are removed laparoscopically.
- Hysterectomy with removal of nearby lymph nodes and part of the vaginal cuff.
- Hysterectomy with bilateral salpingo-oophorectomy is an option avoided in young women because it precipitates an early menopause.
- Pelvic exenteration is a major operation to treat cancer that recurs in the pelvis. It involves removing all of the structures in the pelvis including the uterus, cervix, vagina, ovaries, bladder and rectum and results in a colostomy and a urostomy or ureteric diversion.
Side effects and complications of surgery and their management
Incontinence is a potential problem after a hysterectomy and, on rare occasions, faecal incontinence can occur.
Lymphoedema can occur in one or both legs following lymph node removal.
Early menopause. For patients treated with a bilateral salpingo-oophorectomy there will be an immediate menopause, treated in the majority of patients with Hormone Replacement Therapy (HRT).
For women treated with trachelectomy, pregnancy remains possible, but there is a higher chance of miscarriage. To prevent this, a suture can be placed around the neck of the uterus to provide extra support as the pregnancy develops. Delivery is then performed by caesarian section.
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Radiotherapy
Radiotherapy is usually given after surgery alone. However, radiotherapy in combination with chemotherapy can also be used after surgery.
Treatment planning is an essential part of radiotherapy, using CT, MRI or PET scans to define the area to be treated.
External beam radiotherapy is given on an outpatient basis, as a series of daily treatments (but not usually including the weekend).
Internal radiotherapy or brachytherapy provides radiation directly to the cervix using a radiation source placed in the vagina. The radioactive sources are left in place for a carefully calculated period to give an exact dose of radation. The source can be withdrawn into the safe housing of the machine while other people come into the room. However, visitors are restricted and children are not encouraged to visit.
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Complications and side effects of radiotherapy
Radiotherapy affects normal cells as well as cancer cells. The effects on normal cells will be reduced as much as possible but nevertheless nearby tissues will be affected and as a result, patients experience a range of symptoms.
Vaginal bleeding and discharge immediately after radiotherapy treatment is common but is usually resolved quickly.
Diarrhoea due to rectal inflammation is common and usually goes away after a couple of weeks. A low fibre diet and anti-diarrhoeal medication will help.
Cystitis causing a burning sensation on passing urine can last for about two weeks after treatment. Drinking plently of fluids is helpful. Medication may be needed.
Nausea and sickness are also common during treatment. Anti-emetic medication can help but it is important to maintain a nutritious diet with sufficient calories during treatment, if necessary using high-calorie drinks instead of food.
Sore skin in the treated area is common and can be treated with soothing creams. However, it is best to avoid perfumed soaps, creams or deodorants which may irritate the skin further.
Pelvic radiotherapy affects the ovaries and usually precipitates the menopause about three months after treatment. This can include hot flushes, dry skin, a dry vagina and possible loss of concentration. Most of these symptoms are effectively treated with hormone replacement therapy or avoided by excluding the ovaries from the radiotherapy field.
Tiredness affects many patients treated with radiotherapy. A balance of rest and exercise will help ease this.
Lymphoedema can occur in one or both legs as a result of surgery or radiotherapy, but is more common in patients who have had both surgery and radiotherapy.
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Effects on the bowel and bladder
Sometimes the bowel may be permanently affected by the radiotherapy causing increased bowel motions and diarrhoea.
If the bladder is scarred by radiotherapy, urinary frequency may be a problem.
Sexual intercourse can be painful if the vagina has been scarred by treatment. Vaginal dilators and hormone creams can be helpful for these patients.
Chemotherapy side effects
Chemotherapy does have side effects which vary according to the drugs used and the individual patient's response to them. These may include myelosuppression, anaemia, susceptibility to infection, bruising, nausea and vomiting, hair loss, diarrhoea and mouth ulcers.
Biological treatments - monoclonal antibody treatment
Monoclonal antibodies are used in the treatment of many forms of cancer, but as yet no effective agents have been identified in the treatment of cervical cancer.
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Prognosis
Many factors affect prognosis. These include the stage of the cervical cancer, the patient's age, general health and their individual response to treatment (which will vary). For this reason, statistics can only be considered as a general guide as they are produced by grouping together patients in whom these factors are similar but not identical. These figures are historical (often covering a 10 or 20 years period) and so do not reflect improvements in survival through more modern treatment.
Survival rates indicate the percentage of people who survive the disease for a specific period of time after their diagnosis - usually 5 or 10 years. They will also include patients who are free of the disease, or still undergoing treatment.
The cure rate for cervical cancer confined to the cervix is about 90%.
For patients whose cancer has spread beyond the cervix, the average 5 years survival rate drops to approximately 50%.
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Key Trends
Cervical cancer is becoming less common in Europe, although there are variations in incidence from country to country.
The cervical screening programme has proved very effective in detecting early cancers and pre-cancerous conditions (CIN).
The cervical cancers that do occur in countries with effective screening programmes tend to be faster-growing tumours.
Vaccination against HPV is becoming established in some countries but will not provide complete protection, particularly in women who have been sexually active before vaccination.
Important Research Areas
The use of targeted molecular therapies. As yet, no definite therapies have been identified, but this is an important research area.
The use of imaging technology including CT, MRI and PET scans to further refine treatment planning.
Unresolved Questions
Whether or not the cervical screening programme will be required in 30-40 years' time. If all countries across the world develop vaccination programmes using more effective vaccines than those currently available, cervical cancer could become a disease of the past.
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