this is one cancer that can be prevented
All sexually active women are at risk for the development of cervical cancer. This is one cancer that can be prevented, in most cases, with regular PAP tests to screen for premalignant changes.
The cervix is the part of the uterus connected to the upper vagina. It is the structure that dilates during childbirth to allow the baby to traverse the birth canal.
There are two major types of cancer that develop from the cervix. Squamous cell cancers arise from the squamous epithelium that covers the visible part of the cervix. Adenocarcinomas arise from the glandular lining of the endocervical canal. About 85% of cervical cancers are squamous cell cancers and the remainder adenocarcinomas. Most of these cancers are causally related to human papillomavirus infection (HPV).
Premalignant changes have no symptoms and are usually not noticeable on visual examination.Cervical cancers usually do not spread early. They tend to be slow growing and cause most of their problems in the pelvis. Although distant metastases occur they are usually late events.
Abnormal Discharge and/or Bleeding
There may be no symptoms of a very early cervical cancer, but by the time it is large enough to detect visually it is usually symptomatic with abnormal bleeding. Often this abnormal bleeding occurs after sexual intercourse. Cancers must make new blood vessels as they grow. These new blood vessels are often abnormal and break easily which is why bleeding is a sign of cancer. The cancer also outgrows some of its blood supply, so portions of it are deficient in oxygen. This causes some of the cells to die and for the tissue to become infected. In the cervix this causes a watery or foul discharge that will be noticeable and resistant to most treatments for the usual vaginal infections.
Bladder and/or Kidney Blockage
As the cancer increases in size it usually grows laterally toward the pelvic wall. The tubes from the kidneys (ureters) that bring urine to the bladder pass through this area and they are easily obstructed. If that happens to both of the ureters, then this will result in renal failure, coma and death.
If the cancer grows into the pelvic wall it will press on the nerves that go to the leg and cause unremitting leg pain. These are symptoms of an advanced cancer. Cervical cancers can spread by way of the lymphatic system. The lymphatic vessels drain from the cervix to clusters of lymph glands along the pelvic wall. The lymphatics follow the large blood vessels so the route of drainage is upward along the pelvic wall, then along the midline of the backbone and then to the chest. If the pelvic lymph nodes on one side of the pelvis become obstructed with cancer then that will cause swelling in the leg on that side. This is another sign of advanced cancer.
The diagnosis of cervical cancer is usually not difficult. It is usually big enough to be seen and can be biopsied.
If it arises from up inside the cervical canal then it may not be visible. This will require that a portion of the cervix be removed for diagnosis.
A major mistake is to rely on a Pap test to rule out a cancer in a woman who has symptoms or findings that could be due to a cancer. A normal Pap test never excludes a cancer. Cancer can only be excluded by the proper biopsies. It is known that about 10% of women with an obvious cancer of the cervix will have a PAP test that is essentially normal. This is because there is so much inflammation and dead cell debris that it masks the cancer cells. Very rarely, the cervix may be too small or inaccessible to biopsy properly. In these situations a simple hysterectomy may have to be done for diagnosis.
Many cervical cancers can be treated with radical surgery while larger tumors and more advanced stages require a combination of chemotherapy and radiation.
Radiation therapy usually requires a treatment each day, five days a week, for about five weeks. Each treatment takes about 30 minutes. This is called external or teletherapy. The entire pelvic area is irradiated by an x-ray beam usually generated by a linear accelerator. Everything in the pelvis is irradiated, bladder, rectum, large intestine, small intestine, bone and skin. Following this treatment, a radioactive source is placed inside the cervix and vagina and left in place a few minutes or several days. This is called an implant, radium implant, intracavitary implant or any of several other names. A more accurate term is brachytherapy which means slow therapy.
Stage IA cancers that invade less than 3mm deep can sometimes be treated by simple hysterectomy or even in special cases by cone biopsy. All other Stage I cancers are treated either by radical surgery or radical radiation.
Some stage IIA cancers can also be considered for surgery. Surgery for stage IB and some IIA cancers requires a radical hysterectomy and removal of the pelvic lymph nodes. Radical hysterectomy means that the cervix is removed by staying as far away from it and the cancer as possible. A regular or simple hysterectomy removes the cervix by staying as close to it as possible.
Otherwise, all stage II, III and IV cancers are treated with radiation. Occasionally ultra-radical surgery is done on some stage IVA cancers.
Cancer surgery requires that the cancer be removed with as good a margin of uninvolved tissue as can safely be taken. The radical hysterectomy technique removes all the supporting ligaments to the cervix which means that the dissection is very close to the bladder and to the rectum. The ureters have to be dissected out and the tissue around them removed. A radical hysterectomy with removal of the lymph nodes takes about 3 hours to perform. A simple hysterectomy takes only about 1 hour. The ovaries are not a part of the problem with cervical cancer and can be left in place in young patients. If, after surgery, the pathology indicates that there are positive lymph nodes or that the surgical margins are close, then pelvic irradiation with or without chemotherapy may be advised.
Ultraradical pelvic surgery for advanced or recurrent cancer means that all the pelvic organs are removed. This is called a total pelvic exenteration. The uterus and cervix, vagina, bladder and rectum are removed. Sometimes a vagina can be reconstructed. If the rectum can be reattached then there will be no need for a colostomy. Sometimes a continent urinary reservoir can be constructed. Otherwise a bag will have to be placed for the urine to drain through an ostomy in the abdominal wall. This ultra-radical surgery is done if there is an extensive cancer involving the bladder or rectum, but without spread beyond these structures. It is also done for cancers that recur after pelvic radiation if they are confined to the pelvis.
In general, when cancer of the cervix is being treated with radiation, chemotherapy is also given to increase the effects of the radiation. Otherwise, chemotherapy is not used as initial treatment for cancer of the cervix. There are some investigational studies in which chemotherapy is given first and then either surgery or radiation performed. Chemotherapy may also be initiated in stage IV cases.