Cervical Cancer Treatment

 

Q1 What is Cervical Cancer?

 

A1 The cancer that develops in the cervical tissue is referred to as Cervical cancer. Cervix is the lower part of the uterus or the womb that opens up in the top of vagina. It occurs only in women.

 

Q2 What are the causes of cervical cancer?

 

A2 Cervical cancer is caused by a virus called HPV or Human Papilloma Virus. It is transmitted during sexual intercourse. Most HPV infections go away on their own, however, some may persist and may result in the development of abnormal changes in the cervical cells and eventually cervical cancer.

 

Q3 What is Cervical Pre Cancer?

 

A3 There are abnormal changes in the cells of the cervix. It is referred to as Pre cancer. It is a benign (non cancerous) condition. However, these changes may result in the development of the cervical cancer eventually, if left untreated.

 

Q4 What is the outcome of precancer and cervical cancer?

 

A4  Cervical cancer and pre cancer are completely treatable. The outcome and the treatment options as well are determined by the following factors:

 

• The cancer stage: its size and extent of infliction, whether it has affected cervix partly/completely, restricted to cervix or has spread to other body tissues, lymph nodes

• Type of cervical cancer

• Age of the patient 

• General health of the patient

• Presence of HIV( Human Immunodeficiency virus)

• Newly diagnosed cancer or recurrence of cervical cancer

 

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Q5 Can Cervical cancer be prevented?

 

A5 Certainly Yes. Avoid unsafe sexual practices.The young girls can be vaccinated against the HPV infection by administering HPV vaccines early in life. Regular screening tests help by detecting precancer and thereby resulting in timely medical intervention and prevent development of cervical cancer later in life.

• Making healthy life choices

• Regular cervical cancer screening tests

• Seeking timely treatment

 

Q6 What is cervical screening?

 

A6 Screening tests are the investigations that are carried out on a large group of people to identify the possible existence of a still undiagnosed disease or likelihood of disease in a person, in the absence of any sign or symptom. The screening tests done for detecting any existence of cervical cancer or its likelihood in future constitutes Cervical screening.

 

Q7 When should one start undergoing cervical screening tests?

 

A7 The guidelines vary from country to country regarding the age when the cervical cancer screening should begin. In most countries the age is between 30 to 49 yrs. In some countries the age for screening is as low as 21 yrs.

 

Q8 How often should one undergo cervical cancer screening test?

 

A8 The usual frequency is every 3 yrs for cervical cancer screening. For women who have had abnormal PAP smear may have to get it done more frequently. For HIV+ve patients the screening should be done every year. 

 

Q9 Which screening tests are recommended for cervical cancer?

 

A9 PAP smear is the most common cervical cancer screening test. A test for HPV genetic matirial (DNA) may also be carried out.

 

Q10 What is PAP smear?

 

A10 PAP test involves the collection of cells from the cervix and examining them under the microscope.

 

Q11. What is done if the result of PAP smear or HPV DNA is abnormal?

 

A11 Your specialist may recommend Colposcopy and biopsy if your PAP smear result comes out to be abnormal. Colposcopy refers to visualization of cervix and vagina using special instrument. Biopsy refers to taking a small sample of tissue from the cervix for further testing.

 

Q12 What are the stages of Cervical Cancer?

 

A12 Cervical cancer is put into different categories (staging) depending on the extent of its growth (progression) that is determined by the following factors such as the size of the tumor and the spread of the cancer cells to neighbouring tiissues or other organs of the body. The stages of cervical cancer can be summarized as follows:

 

Stage 0: Non invasive, cancer is restricted to only top layer of the cervical tissue.

 

Stage 1A: Invasive and cancer can only be seen through microscope.The cancer spread is 3 to 5 mm deep and around 7 mm wide. The cancer has spread from top layer to the deeper layer of cervical tissue.

 

Stage 1B: There are two different scenarios in this category. 

 

1. Tumor is  5 mm deep and 7 mm wide. It can only be seen through microscope.

 

2. Tumor is greater than 4 cm in diameter and can be seen without a microscope too.

 

Stage 2A: Cancer extends beyond the cervix into the top 2/3 of vagina sparing tissues around the uterus.

 

Stage 2B: Cancer extends to the tissues around the uterus.

 

Stage 3A: Tumor extends to the lower third of the vagina.

 

Stage 3B: Tumor proliferates to the pelvic wall and/or uterus, ureters the tubes that carry urine from the kidneys to the bladder.

 

Stage 4A: Cancer spreads to the neighbouring pelvic organs such as rectom and urinary bladder and possibly pelvic lymph nodes.

 

Stage 4B: Cancer spreads beyond the pelvic organs to far away organs such as liver, intestine or lungs.

 

Q13 What are the symptoms of Cervical cancer?

 

A13 The patient may present with one or more of the following symptoms in early stages of cervical cancer:

 

• Unusual vaginal bleeding in between periods,after intercourse or after menopause.

• Heavy menstrual flow and for longer duration.

• Vaginal discharge which may be profuse,watery, pale,pink,brown, blood mixed and foul smelling.

• Pain during intercourse(Dyspareunia)

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Patient with advanced cervical cancer may present with:

• Back pain

• Bone pain or fracture

• Fatigue

• Leaking of urine or faeces through vagina

• Leg pain

• Pelvic pain

• Loss of appetite(anorexia)

• Weight loss

• Swelling of single leg

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Q14 What are the treatment options for cervical cancer?

 

A14 The following factors are taken into consideration while determining the best treatment protocol for treating cervical cancer.

 

• The stage of the cervical cancer

• The shape and size of the tumor

• General health of the woman

• Age

• Any desire for future pregnancy

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Early stage cervical cancer can be treated by getting rid of the precancerous or cancerous tissue. There are various surgeries or treatment modalities that can be carried out without fiddling with the uterus or cervix so that the future prospects for having children remain unharmed.They are:

 

• LEEP-Loop Electrosurgical Excision Procedure

• Conization

• Cryotherapy- Abnormal cancer cells are destoyed by freezing them.

• Laser Therapy-Uses light to destroy abnormal cancer cells.

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Treatment options for treating advanced cervical cancer are:

 

• Trachelectomy

• Hysterectomy

• Radical Hysterectomy

• Radiation therapy: To treat the cancer that has proliferated beyond the pelvis or the cancer that has come back.Radiation therapy can be Internal or external radiation therapy. In Internal radiation therapy the source of radiation is placed in the body next to the cervix whereas External radiation involves the emmission of radiation from a big machine placed outside the patient's body to the cancer affected cervix. Radiation therapy may also be given prior to or after the surgery as an adjunctive therapy.

• Chemotherapy: It involves the use of drugs to treat cancer. It may also be given prior to or after the surgery as an adjunctive therapy.

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​Initially in early stages, minimal intervention is adopted such as LEEP, Conization or Simple Total Hysterectomy for those who are above 45 yrs of age and do not desire pregnancy. It has not only diagnostic but also therapeutic importance. In the advanced stages, non adjuvant radiotherapy along with radical surgery is a viable treatment method. For highly advanced stages, palliative treatment is of help, chemotherapy and radiotherapy.

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Q15 What does Radical Hysterectomy involve?

 

A15 Radical Hysterectomy surgery is an elective surgery for treating some cervical cancers. Elective surgery is the one that is planned in advance to treat or manage a condition which is not an emergency, however, it may or may not be medically necessary. Elective word has been derived from Latin word"Eligere" which means to choose. Cervical cancer treatment calls for a multi disciplinary approach which is complex and is determined by several factors such as stage of the cancer, age of the patient, patient's wish to get pregnant and so on.

 

Radical Hysterectomy surgery can be performed by adopting different surgical approaches such as Abdominal, Vaginal, Laparoscopic and Robotic. Hysterectomy refers to removal of uterus or womb. Radical hysterectomy involves removal of uterus, cervix and upper part of vagina. The tissues or ligaments holding the uterus in place are also removed.The ovaries, uterine or fallopian tubes and lymph nodes may be removed as well. Once the surgery is done and required organs are removed, the remaining vagina is stitched back, at the top which is eventually replaced by a scar and close it for good.

 

Removal of ovary/ovaries will be decided by your specialist after taking into consideration several factors. 

• In women less than 40 yrs of age, the specialist will try his/her best to leave at least one ovary to produce enough hormones so that the woman does not experience early menopause. Although, since uterus has already been removed, there will not be any menstrual periods and no way of carrying pregnancy.

• In women between the age of 40 to 50, the surgeon weighs the pros and cons of removing or preserving the ovaries as on one side prevention of the ovarian cancer is the goal and on the other side avoiding sudden early menopause.

• In woman above 50 yrs of age, the specialist most often decides to remove both ovaries.

 

Q16 What are the types of Hysterectomy?

 

A16 Hysterectomy refers to the removal of uterus or womb. In absence of uterus the woman will no longer be able to carry pregnancy. There are different types or variations of hysterectomy. The type of hysterectomy thought to be best for you will be determined by your specialist considering the facts such as the reason for undergoing uterus removal and  to what extent the specialist can spare the reproductive organs in place safely. They can be summarized as below:

 

Depending upon the extent of organ/s removed:

 

Partial, Supracervical or Subtotal Hysterectomy: Removal of uterus leaving behind the cervix(neck of the womb) intact.

 

Total Hysterectomy: Removal of the uterus along with the cervix. One of the most commonly carried out surgery. Ovaries and fallopian tubes(one or both sides) may be removed simultaenously, if surgeon decides to do so. When accompanied by removal of ovaries(Oophorectomy) and fallopian tubes(salpingectomy), the surgery is referred to as Total hysterectomy with Bilateral Salpingo Oophorectomy.

 

Radical Hysterectomy: Radical hysterectomy involves removal of uterus, cervix and upper part of vagina. The tissues or ligaments holding the uterus in place are also removed.The ovaries, uterine or fallopian tubes and lymph nodes may be removed as well. 

 

Q17 What are the different techniques of carrying out Radical Hysterectomy surgery?

 

A17 Different surgical approaches are adopted in order to perform Radical Hysterectomy surgery. They can be summarized as below:

• Open Radical Hysterectomy surgery

• Laparoscopic Radical Hysterectomy Surgery

• Robot-Assisted Radical Hysterectomy Surgery

​Every surgical approach has its own share of pros and cons. Your surgeon will discuss them all in detail with you and decide the best approach for you.

 

Q18 What are the advantages of Robot-Assisted Radical Hysterectomy over Conventional Laparoscopic Radical Hysterectomy surgery?

 

A18 Robot-Assisted Radical Hysterectomy surgery is the most advanced revolutionary treatment approach for Gynecological cancers including cervical cancer. It has shown promising results. It is a minimally invasive surgery done through Da Vinci Robotic surgical system and it has several advantages over conventional Laparoscopic Radical Hysterectomy not only for the patient but also for the surgeon in terms of : 

• 3-Dimensional view of the surgical site allows depth perception, magnification and high resolution of the surgical field all translating to enhanced visualization and better access of the surgical area

• More favorable surgeon’s position resulting in less strain, fatigue resulting in high accuracy and efficiency. (Better ergonomics)

• Improved surgical precision and dexterity

• Specialized surgical instruments are fixed to the robotic arms that ensures well articulated hand and wrist movements, substantially improved range of motion and overcomes surgeon's hand tremors.

• Less pain and hence reduced need for pain medication

• Low rate of complications including infection

 

Q19 What advantages does Laparoscopic Radical Hysterectomy offers over Open Radical Hysterectomy surgery?

 

A19 Laparoscopic Radical Hysterectomy Versus Open Radical Hysterectomy

 

Laparoscopic Radical Hysterectomy has several benefits over traditional open approach. It is a minimally invasive surgery with

 

• Minimal blood loss. Rarely needs blood transfusion

• Less pain, hence less consumption of pain medication.

• Quick recovery

• Reduced hospital stay and therefore cost effective and get to spend more time with family.

• Early resumption of daily activities

 

It is a viable surgical approach for Radical Hysterectomy for cervical cancer in terms of decreased morbidity,  better surgical and overall long term cancer outcome. However, it has its own share of setbacks which makes it a less preferred surgical approach for Radical Hysterectomy, such as

• The surgeon needs to be highly experienced and skilled in order to perform the surgery with laparoscopic approach.

• It provides 2D view

• Restricted movement of the surgical instruments

• Poor, uncomfortable posture of the surgeon (Poor ergonomics)

All the above factors compromise with the overall efficacy and accuracy of the surgery by adversely affecting the surgical performance due to fatigue, tremor and stress, which may be experienced by the surgeon.

 

Benefits of Cervical Cancer treatment in India

 

 

• High quality treatment at the most affordable cost 

• No waiting period

• State of the art world class cancer hospitals with complete cancer care under one roof.

• Most advanced equipment,technology and the latest internationally accepted treatment protocols are adopted.

• Multidisciplinary integrated approach- Team of experts from various disciplines such as Radiation Oncologist,Medical Oncologist,Surgical Oncologist, Gynaecologist or specialist of the concerned specialty, all work in coordination taking consolidated review of your condition, right from the screening,diagnosis,treatment and rehabilitation to bring out the best clinical outcome for the patient.

• Globally trained, highly experienced doctors.

• Great ambience.

• Compassionate staff to look after.

• Hospitals accredited with international organizations such as JCI(Joint commission International) for quality standards.

• Language no barrier. English speaking people and if required, translators are available for your convenience.

• Most economical accommodation available at a walking distance from the hospital. Wide range of options starting from guest house, service apartments to five star hotels, best suited to your budget and choice.

• Good flight connectivity.

• India has a diverse and rich cultural heritage. You can witness its beauty and uniqueness. It offers most conducive environment for recuperation.

Dr Sabhyata Gupta

MBBS,MD(Gynaecology)

Trainings:

• Robotic Gynaecological surgery training ( France)

• Observership training programme in Uro-gynaecological Oncology at Tata Memorial Cancer Hospital, Mumbai, India

• Diploma-Gynaecological Endoscopic Surgery University Hospitals Schieswig–Holstein, Kiel (Germany) 

• Indo German Training Course in “Advanced Endoscopic Surgery in Gynecology at Giessen School of Endoscopic Surgery (Germany)

Director, Department of Gynaecology and Gynaec-Oncology

Medanta The Medicity, Gurgaon,Delhi-NCR

Dr Jyoti Mishra

MBBS,MD(Gynaecology and obstetrics),

Dip. in Gynaec Endoscopy,Kiel,Germany

Associate Director,Dept. of Gynaecology and Obstetrics

Jaypee Hospital, Noida, Delhi-NCR