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The cervix is the muscular lower portion of the uterus that holds in pregnancies and dilates during labor. Cervical cancer occurs in several forms. The most common is squamous cell carcinoma, which accounts for 85 to 90 percent of cervical cancers. Other forms include adenocarcinomas and combination cancers such as adenosquamous carcinoma. Some strains of the human papillomavirus (HPV), a virus transmitted during sex, play a role in causing most cases of cervical cancer. CERVICAL CANCER OVERVIEW As per WHO cervical cancer is the second biggest cause of female cancer mortality worldwide with 288, 000 deaths yearly. About 510, 000 cases of cervical cancer are reported each year with nearly 80% in developing countries. Most of the deaths could be prevented, if more women had tests to find cervical cancer early. Dharamshila Hospital And Research Centre is one of the top cancer hospitals of India for advanced cancer treatment. Dharamshila Hospital offers comprehensive care for patients with Cervical Cancer, including advanced diagnosis and best treatment options. The Department has been regularly carrying out radical surgeries for all gynecological cancers and achieving good results. Such radical surgeries, require additional training and experience compared to general gynecology. In addition, management of cancer today follows a multimodal approach, and integration of surgery with non-surgical treatments such as, chemotherapy and radiation therapy is essential to improve outcome. Gynecological oncologists are best suited for this as they are focusing only on gynecological cancers. What is Cervical Cancer The cervix is the muscular lower portion of the uterus that holds in pregnancies and dilates during labor. Cervical cancer occurs in several forms. The most common is squamous cell carcinoma, which accounts for 85 to 90 percent of cervical cancers. Other forms include adenocarcinomas and combination cancers such as adenosquamous carcinoma. Some strains of the human papillomavirus (HPV), a virus transmitted during sex, play a role in causing most cases of cervical cancer. TYPES OF CERVICAL CANCER • Premalignant conditions of the cervix are identified as the presence of cells that appear to be abnormal, but are not cancerous at the present time. However, the appearance of these abnormal cells may be the first evidence of cancer that develops years later. Premalignant changes of the cervix usually do not cause pain and, in general, do not cause any symptoms. They are detected with a Pap test. • High-grade squamous intraepithelial lesions (SIL) means there are a large number of precancerous cells on the surface of the cervix. The cells often do not become cancerous for many years. High-grade lesions may also be called moderate or severe dysplasia, or cervical intraepithelial neoplasia (CIN) 2 or 3. They develop most often in women between the ages of 30 and 40, but can occur at any age. • Invasive cervical cancer If abnormal cells on the surface of the cervix spread deeper into the cervix, or to other tissues or organs, the disease is then called cervical cancer, or invasive cervical cancer. CERVICAL CANCER SYMPTOMS The most common symptom is abnormal bleeding, which may: • start and stop between regular menstrual periods. • occur after sexual intercourse, douching or a pelvic exam. Other symptoms may include: • heavier menstrual bleeding, which may last longer than usual • bleeding after menopause • increased vaginal discharge • pain during intercourse • Low back pain • Blood in your urine • Pelvic pain • Swelling in one leg • Unexplained weight loss or gain If any of these symptoms persist, see your gynaecologist / gynaeoncologist immediately. CERVICAL CANCER DIAGNOSIS The role of the Pap smear is to screen for cervical cancers and cervical pre-cancers. In its early stages, cervical cancer usually has no symptoms. To diagnose cervical cancer, gynaeoncologist first performs the following procedures: • Pap smear. In this test, gynaeoncologist collects cells from the cervix during a vaginal exam to look for abnormal, or precancerous, changes in the lining of the cervix • Colposcopy. If the Pap smear results are abnormal, gynaeoncologist may check the cervix using a magnifying lens (colposcopy) and collects and examines cells (biopsy) to determine whether cancer is present. If the exams reveal precancerous changes in cells, such as CIN (Cervical Intraepithelial Neoplasia) or carcinoma in situ, gynaeoncologist may remove tissue with LEEP / Laser Excision or destroy with electric / cryo cauterization or laser vaporization. If the exams show invasive cancer, gynaeoncologist will order more tests to determine the extent of the cancer. These tests might include: • Physical exam. This exam involves per vaginum bimanual and per rectal examination. • Cystoscopy. Gynaeoncologist examines the bladder using a lighted scope. • Rectosigmoidoscopy. Gynaeoncologist visually inspects the rectum to determine if cancer is present. • Positron emission tomography (PET) scan. This scan can detect the spread of cancer beyond the cervix or to nearby lymph nodes. • Computed tomography (CT) scan. A CT scan can show the extent of spread of cancer especially in lymph nodes. • Intravenous Pyelogram. Gynaeoncologist injects a special dye into the vein and takes an X-ray of the urinary system. • A chest X-ray – As part of metastatic work up and several physical check up. • Blood tests. Based on the doctor's evaluation, the cancer will be classified into one of more than 10 substages. Staging helps gynaeoncologist determine what treatments may be more effective. In general, stages for cervical cancer include: • Stage 0 or carcinoma in situ. Stage 0 cancer is preinvasive cancer, and abnormal cells appear only in the first layer of cells that line the cervix. • Stage I. Stage I cancer is confined to the cervix. Gynaeoncologist may further classify it as Stages IA1, IA2, IB1 or IB2 depending on the size of the tumor and how deeply the cancer has invaded. • Stage II. Stage II cancer has spread beyond the uterus, but not to the pelvic sidewall or the upper third of the vagina. Gynaeoncologistmay classify it as Stage IIA or IIB. • Stage III. In Stage III, the cancer extends to the pelvic wall or the lower third of the vagina or causes expansion of the ureters, resulting in kidney problems. Gynaeoncologistmay classify it as Stage IIIA or IIIB based on whether cancer cells have extended to the sidewall of the pelvis. • Stage IV. In Stage IV, the cancer has invaded the bladder or rectum and may extend beyond the pelvis. Gynaeoncologistmay identify it as Stage IVA or IVB. CERVICAL CANCER TREATMENT Gynae oncologists, medical oncologists and radiation oncologists work together at DHRC to tailor treatment to the needs. For most Stage I and II cancers of the cervix, you'll have a choice of surgery or combined chemotherapy and radiation therapy. If the cancer is more advanced, gynaeoncologist may recommend a combination of treatments that could include surgery, chemotherapy and radiation therapy. Types of surgery Gynaeoncologists at DHRC perform many procedures based on the stage of disease and the needs of the patient. Gynaeoncologist may recommend: • Cervical cone biopsy (conization). Using a scalpel, Gynaeoncologist removes a cone-shaped piece of cervical tissue where the abnormality is found. • Laser surgery. A narrow beam of intense light is used to kill abnormal cells. Surgeons usually perform this surgery to remove precancerous cells. • Loop electrosurgical excision procedure (LEEP). In this procedure, Gynaeoncologist uses a wire loop to pass electrical current, which cuts diseased tissue from the cervix. • Cryosurgery. Gynaeoncologist kills cancerous and precancerous cells by freezing them. • Simple hysterectomy. In this procedure, Gynaeoncologist removes the cervix and uterus. • Radical hysterectomy. In this procedure, the surgeon removes the cervix, uterus and surrounding tissue. • Lymphadenectomy. In a lymphadenectomy, Gynaeoncologist removes the lymph nodes that drain the cervix. • Exenteration. Gynaeoncologist may recommend exenteration if you have an advanced cancer that has spread to organs next to the cervix but not to distant parts of the body, or when following previous treatment. This surgery involves removal of the uterus, cervix, lymph nodes and possibly the bladder, vagina, rectum and part of the colon. • Reconstructive surgery. Often used to treat advanced cases of cervical cancer, reconstruction may be necessary for the vagina, bladder, pelvic floor and parts of the pelvis. Radiation therapy Radiation therapy is often the most effective treatment for cervical cancer at any stage of development. At DHRC, state-of-the-art radiation therapy includes: • Intensity-modulated radiation therapy (IMRT). This form of external radiation minimizes the high-dose radiation applied to healthy tissue around the tumor. Doctors also aim external beam radiation at lymph node tissue in the pelvis that the cancer has invaded. • Brachytherapy. Brachytherapy is internal radiation directed into the vagina and uterus. You can receive Brachytherapy in the outpatient setting. Chemotherapy Chemotherapy uses anti-cancer drugs given intravenously or by mouth to destroy cancerous cells. Doctors prescribe higher doses of chemotherapy when the cancer has spread beyond the tumor or if the cancer returns after initial treatment. Studies show that low-dose chemotherapy, when combined with radiation therapy, improves survival rates in women who have advanced cervical cancer. Reconstructive surgery At DHRC, gynaeoncologist and a plastic surgeon work together to restore as much anatomy and function as possible through reconstructive surgery. This teamwork is especially important in radical cancer surgery that includes surgical reconstruction as part of the treatment plan. Reconstructive surgical procedures include: • Rebuilding the vagina. Surgeons may rebuild the vagina after radical cancer treatment. • Skin grafts. The doctor may recommend skin grafts to cover large treated areas after radiation therapy or radical surgery for recurrent cancer in the vulva or groin. • Rebuilding vital organs. Gynaeoncologist may rebuild vital organs (such as a urinary bladder, vagina or pelvic floor) that were removed to treat advanced cancer or were damaged during radiation therapy. In the case of bladder reconstruction, for example, Gynaeoncologist may be able to create a pouch that holds the urine internally, eliminating the need for an external collection bag. • Pelvic floor reconstruction. Reconstruction of the pelvic floor can correct pelvic prolapse and urinary or rectal incontinence. Oncologists will discuss the concerns and expectations as well as possible approaches to treatment and reconstruction and work with you to determine the most appropriate treatment. Reconstructive surgery techniques can produce cosmetically pleasing and functional results that improve the quality of life.
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