Cervical cancer as the name suggests is when abnormal cancer cells develop in the cells of the cervix — the fibro-muscular lower part of the uterus that connects to the vagina.

In the vagina the cervix looks similar to puckered lips. It widens during childbirth to allow for the passage of the baby. It also allows menstrual fluid from the womb to the outside and is the passage through which sperm travel to reach the uterus and the female egg(s) for conception.

Human papillomavirus (HPV) is a common viral infection of the mucosa lining which includes the female genital tract. Most sexually active adults would have been infected, cleared the infection and may be repeatedly infected unknowingly. Cervical conditions rarely present symptoms in the early stages.

Cervical cancer is by far the most common HPV-related disease. Nearly all cases of cervical cancer (99%) can be attributable to HPV infection. Other HPV types also causes a proportion of cancers of the anus, vulva, vagina, penis and oropharynx,

How HPV infection leads to cervical cancer

Although most HPV infections clear up on their own and most pre-cancerous lesions can resolve spontaneously, there is a risk for all women that HPV infection may become chronic and pre-cancerous lesions progress to invasive cervical cancer.

It takes 10 years or more for cervical cancer to develop in women with normal immune systems. It can take less than 10 years in women with weakened immune systems, such as those with untreated HIV infection.

HPV vaccination

The different brands of HPV vaccines can help prevent infection from both high risk HPV types that can lead to cervical cancer and low risk types that cause genital warts.

HPV vaccines work best if administered prior to exposure to HPV. Therefore, WHO recommends to vaccinate girls and boys, aged between 9 and 14 years, when most have not started sexual activity as the vaccine produces a stronger immune response when taken during the preteen years.

Up until age 14 years, only two doses of the vaccine are required and for those 15 years and older, a full three-dose series is needed. The vaccine is available up to age 26 years. Any request for older patients would be at the discretion of the Doctor.

The vaccines do not treat HPV infection or HPV-associated disease, such as cancer. HPV vaccination does not replace regular cervical cancer screening.

 

PREVENTION AND TESTING

Primary prevention begins with HPV vaccination of girls and boys aged 9-14 years, before they become sexually active.

Other recommended preventive interventions for boys and girls as appropriate are:

  • education about safe sexual practices, including delayed start of sexual activity;
  • promotion and provision of condoms for those already engaged in sexual activity;
  • warnings about tobacco use, which often starts during adolescence, and which is an important risk factor for cervical and other cancers; and
  • male circumcision.

Screening and treatment of pre-cancer lesions

Cervical cancer screening involves testing for pre-cancer and cancer among women who have no symptoms and may feel perfectly healthy. When screening detects pre-cancerous lesions, these can easily be treated, and cancer can be avoided. Screening can also detect cancer at an early stage and treatment has a high potential for cure.

Early Detection is key.

Screening is recommended for every woman from aged 21years to 65 years.

For women living with HIV who are sexually active, screening should be done earlier and regularly, as soon as they know their HIV status.

There are 3 different types of screening tests that are currently recommended by WHO:

  • HPV testing for high-risk HPV types.
  • Visual Inspection with Acetic Acid (VIA) for low to middle income countries
  • Conventional (Pap) test
  • Gold Standard Liquid-based cytology (LBC)
  • Co-testing (LBC + HPV test) are recommended for women over 30.

Screening has to be linked to access to treatment and management of positive screening tests. Screening without proper management is not ethical.

Management of invasive cervical cancer

When a woman presents symptoms of suspicion for cervical cancer, she must be referred to an appropriate facility for further evaluation, diagnosis and treatment.

Symptoms of early stage cervical cancer may include:

  • Irregular blood spotting or light bleeding between periods in women of reproductive age;
  • Postmenopausal spotting or bleeding;
  • Bleeding after sexual intercourse; and
  • Increased vaginal discharge, sometimes foul smelling.

As cervical cancer advances, more severe symptoms may appear including:

  • Persistent back, leg and/or pelvic pain;
  • Weight loss, fatigue, loss of appetite;
  • Foul-smell discharge and vaginal discomfort; and
  • Swelling of a leg or both lower extremities.

Other severe symptoms may arise at advanced stages depending on which organs cancer has spread.

Diagnosis of cervical cancer must be made by histopathologic examination. Staging is done based on tumor size and spread of the disease within the pelvis and to distant organs. Treatment depends on the stage of the disease and options include surgery, radiotherapy and chemotherapy. Palliative care is also an essential element of cancer management to relive unnecessary pain and suffering due the disease.

References

  • Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer.
  • Mayo Clinic in Rochester, Minn., and Mayo Clinic in Phoenix/Scottsdale, Ariz
  • Author:InaPark,MD,MS
    Associate Professor, University of California San Francisco School of Medicine; Medical Director, California Prevention Training Center, Oakland, California
  • Author:DavidL.Bell,MD,MPH
  • Associate Professor of Pediatrics at Columbia University Medical Center; The Young Men’s Clinic, New York, New York