Cervical cancer is the most common preventable cancer if the abnormal changes are identified early and treated in time. It is a silent killer which most women are unaware of. It is caused by a virus known as HPV(Human Papilloma Virus). You can completely protect yourself from it by undergoing regular screening tests, getting HPV vaccine and adopting safe sexual practices.
Q1 What is Cervical Cancer?
A1 CERVICAL CANCER: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 CAUSES OF CERVICAL CANCER: 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 CERVICAL PRE CANCER: 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 OUTCOME: 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
Q5 Can Cervical cancer be prevented?
A5 PREVENTION OF CERVICAL CANCER: Yes, it can Certainly be prevented.
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 CERVICAL CANCER SCREENING: 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 RECOMMENDATIONS REGARDING APPROPRIATE TIME FOR CERVICAL CANCER SCREENING 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 FREQUENCY OF CERVICAL SCREENING: 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 material (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)
Patient with advanced cervical cancer may present with:
Bone pain or fracture
Leaking of urine or faeces through vagina
Loss of appetite(anorexia)
Swelling of single leg
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
Any desire for future pregnancy
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
Cryotherapy- Abnormal cancer cells are destoyed by freezing them.
Laser Therapy-Uses light to destroy abnormal cancer cells.
Treatment options for treating advanced cervical cancer are:
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.
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.
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.
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.
Q20 What effect does my cervical cancer treatment will have on my fertility?
A20 Fertility and Cervical Cancer Treatment
Your doctor will devise an appropriate treatment plan for you that will take care of your cervical cancer as well as your desire for pregnancy.
In case of Early cervical cancer, every effort would be made to go for a surgery that leaves the womb intact, though, removes the cancerous tissue. The type of surgical procedure may be
Cone Biopsy or LLETZ (large Loop Excision of the Transformation Zone) This procedure removes only a small part of the cervix. Premature birth of the baby may be a possibility.
Radical Trachelectomy This surgery involves removal of part of the cervix and upper part of vagina. Internal opening of the cervix is permanently stitched. The delivery will have to be carried out through cesarean section as the cervix is closed permanantly. There is a possibility of premature child birth.
Some treatments like surgery that removes the womb, radiotherapy and some chemotherapy medicines may affect the normal function of ovaries and therefore have negative impact on fertility.
If you wish to get pregnant, you need to discuss it with your specialist so that the treatment can be planned accordingly.
Dr Sabhyata Gupta
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
Saket, New Delhi
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