Some Important Numbers
- Cervical cancer is the second most common cancer among women worldwide, with an estimated 527,624 new cases and 265,653 deaths.
- The incident mortality ratio is 52 per cent.
- It is often the most common cancer among women in the developing countries, and account for 88 per cent of the cases.
- Cases and deaths have declined markedly in the last 40 years in most industrialized countries, partly owing to a reduction in risk factors, but mainly as a result of extensive screening programmes.
Pathological Picture of Cancer of The Cervix
Natural history of a disease describes the way in which a disease evolves over a period of time from its earliest (prepathogenesis) stage to its termination as recovery/ disability/ death, in the absence of treatment or prevention.
Natural history of cervical cancer :-
a. The Disease:
- Cancer cervix seems to follow a progressive course from epithelial dysplasia to carcinoma in situ to invasive carcinoma. In simple words, carcinoma in situ means malignant changes that still have not breached the basement membrane and did not start local infiltration.
- According to a substantial amount of evidence, carcinoma in situ persists for a long time, more than 8 years on average.
- Once the invasive stage is reached, the disease spreads by direct extension into the lymph nodes and pelvic organs.
b. Causative agent:
- There is evidence pointing to Human Papilloma Virus (HPV) - sexually transmitted - as the cause of cervical cancer.
- This virus was once supposed to produce only vegetant warts, but now acknowledged as responsible for a much wider clinical and sub clinical lesions.
- The virus is found in more than 95% of the cancers.
- Current evidence suggests that the virus is necessary but not the sufficient cause of the disease and researchers are now trying to define other co-factors.
Natural History of Cervical Cancer In Brief
A. AGE: It affects relatively young women with incidence increasing rapidly from the age of 25 to 45.
B. GENITAL WARTS: Past/ present occurrence of clinical genital warts is an important risk factor.
C. MARITAL STATUS: The disease is linked with sexual intercourse.
D. EARLY MARRIAGE: Early marriage, early coitus, early childbearing and repeated childbirth have been associated with increasing risk.
E. ORAL CONTRACEPTIVE PILLS: There is renewed concern about the possible relationship between pill use and the development of invasive cervical cancer. A recent World Health Organization (WHO) study finds an increased risk with increased duration of pill use and with the use of oral contraceptives high in oestrogen.
F. SOCIO-ECONOMIC CLASS: It is more common in lower socioeconomic groups reflecting probably poor genital hygiene,
Staging of The Disease
The staging of cervical cancer is clinical and generally completed with a pelvic examination under anaesthesia with cystoscopy and proctoscopy. Chest x-rays, intravenous pyelograms, and computed tomography are generally required, and magnetic resonance imaging (MRI) can be used to detect extracervical extensions.
Stage 0- Carcinoma in situ
Stage I- Disease confined to the cervix.
Stage II- Disease invades beyond cervix but does not extend to the pelvic wall or lower third of vagina.
Stage III- Disease extends to lower third of vagina or to the pelvic wall or causes hydronephrosis.
Stage IV- Tumor invades the mucosa of bladder or rectum or extends beyond the true pelvis.
Symptoms of Cervical Cancer
The most common symptoms are listed as follows. One should not hesitate to consult a doctor even if just one of them is present. Remember the prognosis heavily depends on the stage of detection.
- Abnormal bleeding or postcoital spotting that may increase to intermenstrual or prominent menstrual bleeding.
- Pain during sexual intercourse.
- Yellowish foul smelling vaginal discharge.
- lumbosacral back pain.
- urinary symptoms.
- The Pap (papanicolaou) smear is 90 to 95% accurate in detecting early lesions such as CIN but is less sensitive in detecting cancer
- Inflammation, necrosis and hemorrhage may produce false positive smears, and colposcopy directed biopsy is required when any lesion is visible on the cervix, regardless of Pap smear findings.
- The American Cancer Society recommends that women after onset of sexual activity, or above the age of 20, have two consecutive yearly smears. If negative, smear should be repeated every 3 years.
- The American College of Obstetrics and Gynaecology recommends yearly Pap smear with routine annual pelvic and breast examinations.
Prevention and Control
1. Primary Prevention: Until the causative factors are more clearly understood, there is no prospect of primary prevention. It may be that with improved personal hygiene and birth control, cancer of the cervix and uterus will show decline.
2. Secondary Prevention: This rests on early detection of cases through and treatment by radical surgery and radiotherapy. The 5-year survival rate is virtually 100 per cent for carcinoma in situ. 79 per cent for local invasive disease. Cancer cervix is difficult to cure once symptoms develop and is fatal if left untreated. Prognosis is strongly dependent upon the stage of disease at detection and treatment.
Treatment According to Stage
- Stage 0- Cone biopsy or abdominal hysterectomy.
- Stage I- Results appear equivalent for radical hysterectomy or radiation therapy.
- Stage II to Stage IV- Radical radiation therapy or combined modality therapy.
Reconstruction of rectum, vagina, and bladder can often be done following the surgical procedure.