Introduction
In 2004 almost 31,000 women were diagnosed with cancer of the cervix in the 25 countries of the European Union and as many as 52,000 new cases were diagnosed in Europe as a whole. But between EU member states, there is a considerable difference in both the number of new cases and the effectiveness of treatment. More than one in every 100 women in the 10 newest EU member states dies from cervical cancer before the age of 75, twice as many as in the old 15 member states. Lithuanian women are 8 times more likely to die from the disease compared with women in Finland, where the rate is lowest. Mortality rates in Eastern Europe today are similar to those observed in Western Europe several decades ago. Cervical screening and treatment are now producing better results.
Cancer of the cervix often affects women under 35 years old, and is the second most common form of cancer in this age group – only breast cancer occurs more frequently. In the 15 old EU countries, the fight against cervical cancer is a success story due to the cervical smear screening programme that has led to so many cases being diagnosed early, which in turn means that cures can be achieved.
There are two main types of cervical cancer. The most common type is squamous cell carcinoma which develops from the cells (similar to skin cells) that cover the outer surface of the cervix, at the top of the vagina. The less common adenocarcinoma develops from cells lining the glands found in the inner part of the cervical canal, the endocervix. Because adenocarcinoma starts inside the cervical canal, it can be more difficult to detect using cervical smear screening tests.
Cervical cancer takes years to develop, and usually follows changes to the cells in the cervix. The technical name for these changes is Cervical Intraepithelial Neoplasia, abbreviated to CIN. If left untreated, CIN can develop into cervical cancer.
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The Cervix
The uterus and the cervix are only present in women. The cervix is the lower part of the uterus (or womb) and is often called the neck of the womb. The uterus is a muscular, pear-shaped organ, with the cervix at the top of the vagina. In front of the cervix are the bladder and urethra – the tube that empties the bladder - and behind the cervix is the rectum or back passage. Close to the cervix is a collection of lymph nodes.
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Cervical Cancer
All cancers are uncontrolled growths of cells. In cervical cancer, this uncontrolled growth happens in the cells on the inside or outside of the cervix, and gives rise to two different types of cancer. On the outside of the cervix the cells are very similar to skin cells but moist, and these give rise to the most common form of cervical cancer known as squamous cell carcinoma. On the inside of the cervix – the cervical canal leading up into the uterus - cancer can arise from the glands, which produce cancers called adenocarcinomas.
Not all cervical cancers are the same or behave in the same way - some cancers are relatively slowly growing, but others are more aggressive.
One of the characteristics of cancer is that it can spread to other parts of the body, either by directly invading neighbouring areas or because the cancer cells travel through the blood or lymphatic system to other areas. Cervical cancer may spread to surrounding structures such as the uterus, vagina, bladder and rectum, as well as though the blood stream to other organs of the body including the liver and the bones.
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Cervical Cancer Risk Factors
There is no method of eliminating the risk of cervical cancer altogether, but there are clear risk factors which increase the chances of developing cervical cancer.
Most cases of cervical cancer result from infection with the Human Papilloma Virus (HPV). There are many different types of HPV which are common and passed on during sexual intercourse. Most women who are, or have been, sexually active will be infected with HPV from time to time, but the body’s defence system usually destroys the virus. Different types of HPV can also cause other problems such as genital warts.
If the virus is not destroyed there is the chance of developing Cervical Intraepithelial Neoplasia or CIN. CIN cells are not in themselves cancerous, although they can become so and, therefore, are sometimes referred to as pre-cancerous. CIN cells are also referred to as dysplastic or dyskaryotic cells. All these terms mean the same thing - that the cells might develop into cancer if they are not treated.
Being sexually active at an early age and having multiple sexual partners does increase the risk of cervical cancer, as this increases the chances of catching HPV. But as HPV is common, it is possible to contract HPV infection from just one sexual partner.
Because there are changes in the cells of the cervix which can be detected before cancer develops, the cervical screening programme is very effective in detecting women who may go on to develop cancer.
A poor immune response increases the chances of CIN developing into cervical cancer. Smoking, poor diet, drugs used to treat other cancers, auto-immune diseases, and other infections such as HIV are all risk factors.
Long term use of the contraceptive pill (i.e. more than 10 years) also slightly increases the risk of developing cervical cancer.
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Preventing Cervical Cancer
Where cervical screening is available to all women, it is the most effective means of identifying women at risk of developing cervical cancer or diagnosing cancer in women who have no symptoms of the disease. It detects the early changes in cervical cells so that with treatment the progression to cancer can be prevented.
Two types of screening test are used. One method is a direct smear of cells taken from the cervix using a small spatula or brush and spread onto a slide for examination under a microscope. Alternatively a small sample of cells taken from the cervix is suspended in a liquid before being examined under a microscope (liquid-based cytology).
It is best to have a cervical smear taken in the middle of your menstrual cycle. It is more difficult to take a smear during menstruation when there may be an inadequate result which means the test must be repeated.
Vaccination for girls against some forms of HPV is now being introduced in some countries, which will further reduce the number of new cancer cases. However, even where a vaccination programme is in place, it will take years before all women at risk are protected (see section on vaccination below).
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HPV Vaccination
Vaccines have now been developed against HPV. There are a large number of strains of HPV and different vaccines provide protection against different strains of the virus.
Vaccines are most effective in women who have not been exposed to HPV infection and so are best given to females who have not been sexually active. Vaccination programmes are therefore 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 if given to men.
Cervarix® provides immunity to HPV types 16 and 18 which are responsible for approximately 70% of all cervical cancers.
Gardasil® provides immunity to HPV types 6, 11, 16, and 18 responsible for approximately 75% of all cervical cancers.
Three injections are given over a six month period, and a booster may be required after some years.
Possible side effects include pain and swelling where the vaccination is given. Very rarely allergic reactions may occur.
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Symptoms of Cervical Cancer
Often there are no symptoms to indicate that there is anything wrong. In the early CIN stages, when the cells are abnormal and have the potential to develop into cancer, symptoms are rare. Even in the early stages of cervical cancer patients have no symptoms, which is why attending regular cervical screening is so important.
But where there are symptoms, they typically include:
- bleeding after sexual intercourse
- bleeding between menstrual periods
- bleeding after the menopause
- discomfort or pain during sex
- an unusual vaginal discharge
These symptoms may be due to a variety of conditions just one of which is cancer of the cervix but women, and particularly younger women, with these symptoms should seek medical advice quickly.
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Treating 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 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.
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Treating Cervical Cancer
Successful treatment of cervical cancer requires a team of health professionals, each with their own expertise. This will include a gynaecologist, pathologist, radiation oncologist and their support teams. Together, they analyse information about the exact type of cancer, how fast the tumour is growing, and whether there has been any spread to other areas of the body. They will also consider the patient's general health and their own preferences with regard to treatment. Ultimately, the choice of treatment rests with the patient, based on the advice of all the specialists involved.
Surgery, radiotherapy and chemotherapy can all be used to treat cervical cancer. Early cervical cancer can usually be cured. The radiotherapy options include internal radiotherapy (brachytherapy) and external beam treatment.
Surgery
Some very early small cervical cancers can be treated by taking a cone biopsy - cutting away a wedge of the cervix, or removing the cervix completely but leaving the rest of the uterus in place. If these procedures are used it is possible, but not guaranteed, that patients will be able to have children afterwards.
Surgical treatment usually involves complete removal of the uterus and cervix (hysterectomy) and sometimes removal of the ovaries and lymph nodes as well – exactly what is recommended depends on whether the cancer is just in the cervix or has spread to other parts of the uterus and the tissues around it.
About 20% of patients will need radiotherapy after surgery. This is usually because the cancer has not been completely removed or there are cancer cells in nearby lymph nodes.
Radiotherapy
There are two main forms of radiotherapy used in the treatment of cervical cancer – brachytherapy and external beam radiation. But before any treatment is given, there is a careful assessment and planning process to make sure that the right dose of radiation is given to exactly the right area so that the cancer is treated but the effect on the surrounding tissues is as little as possible.
This process involves building up a very clear picture of the tumour using CT or MRI scans. Using this information a unique treatment programme is built up for each patient.
Brachytherapy
Brachytherapy is a type of radiotherapy where radioactive material is placed against, or in, the cervix and gives a high dose of radiation to all the nearby tissues.
One way of delivering brachytherapy is to position a radioactive source in a metal applicator, in the vagina. The radioactive source is held place for 2 or 3 days, or placed in the vagina 3 or 4 times for several hours, depending on the required dose of radiation.
Another option is to place small metal rods in the vagina, which are then filled with tiny radioactive metal pellets.
Radiotherapy can cause a few side effects including:
- diarrhoea
- cystitis
- an inflamed bladder (urine has to be passed more often and there may be some pain on passing urine)
- nausea (feeling sick)
- discomfort in the vagina
- possibly some vaginal bleeding
During the treatment, anyone visiting you will also be exposed to some radiation. Pregnant women and children should not come to see you during the treatment and other visitors should only stay for short periods of time. Once the treatment is finished you will not be radioactive so it is perfectly safe to be with other people, including children.
External Beam Radiotherapy
External beam radiotherapy uses high energy X-ray beams generated from machines to kill cancer cells. Some normal cells will also be affected, but the treatment is planned so that the radiation is focused on the affected areas from a variety of different angles. Therefore, normal tissues receive a much smaller dose. In addition normal cells are better at repairing themselves than cancer cells.
External beam radiotherapy is normally given as a series of short regular treatments in a radiotherapy department (each treatment may be referred to as a fraction).
All radiotherapy treatment is delivered to an area that follows as closely as possible the shape of the cancer. This avoids giving high dose radiation to neighbouring healthy tissue and results in fewer side effects.
Radiotherapy is carefully planned, using a simulator, which uses X-rays or CT scans to plan the treatment, so that the effect is greatest on cancer cells whilst healthy cells receive the smallest possible dose of radiation.
The actual treatment only takes a few minutes and does not hurt. However, it is very important to lie still during treatment so that the radiotherapy hits the cancer cells and not normal cells close by.
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Looking after Yourself
Radiotherapy for cervical cancer, as the sole treatment or in combination with surgery, is highly effective for many patients but can cause a number of side effects. Some patients will not experience any side effects, whilst others may have several that are troublesome. Fortunately many of these side effects disappear soon after the treatment ends and the symptoms can usually be treated, so if you do experience any problems it is important to mention them to your doctor or nurse, so they can give you the treatment you need.
Diarrhoea may occur during radiotherapy, and can be treated with medication if necessary. Many clinicians suggest that a low residue diet is helpful but not everyone agrees with this approach. Diarrhoea quickly clears up once treatment is finished.
Cystitis due to the radiation treatment is also common, having to pass urine more frequently, sometimes with discomfort or a stinging pain. In most cases this will be helped by drinking plenty of fluids, but many doctors will check to make sure that there is no infection present. If there is an infection antibiotics will be prescribed.
Skin irritation between the buttocks and between the legs usually responds well to treatment with hydrocortisone cream or ointment.
Whatever the problem, do not assume that nothing can be done about it – ask your doctor or nurse: do not just grin and bear it.
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Questions for your Doctor
Before making up your mind about the best treatment option for you, you will need information about your cancer, the treatments available in your area and what they will entail, what to expect from the treatment, what side effects you might experience and how these may change over time as well as what your doctors believe would be most effective in combating your cancer.
For different patients the answers will be different, so it is important to discuss all these issues with your doctor so that you are able to make the right choice for you.
You will have your own questions but some issues you might want to raise are:
- What does the treatment involve?
- What are the benefits that I might get?
- How good are my chances of getting those benefits?
- Could having treatment make me feel worse? If so, in what way?
- Are there alternative treatments?
- What are the risks of the treatment?
- Are the risks minor or serious? How likely are they to happen?
- What care will I need after treatment?
- What happens if something goes wrong?
- What may happen if I don’t have the treatment?
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Conclusion
The treatment of cervical cancer is a success story. Although some forms of cervical cancer are becoming more common, the cervical smear screening programme leads to many cases being diagnosed early, which in turn means that cures can be achieved.
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