Cervical cancer is a malignancy of the cervix. It may present with vaginal bleeding but symptoms may be absent until the cancer is in its advanced stages, which has made cervical cancer the focus of intense screening efforts utilizing the Pap smear. In developed countries, the widespread use of cervical screening programs has reduced the incidence of invasive cervical cancer, by 50% or more. Most scientific studies have found that human papillomavirus (HPV) infection is responsible for virtually all cases of cervical cancer Treatment consists of surgery (including local excision) in early stages and chemotherapy and radiotherapy in advanced stages of the disease. An effective HPV vaccine against the two most common cancer-causing strains of HPV has recently been licenced in the US . These two HPV strains together are responsible for approximately 70% of all cervical cancers. Experts recommend that women combine the benefits of both programs by seeking regular Pap smear screening, even after vaccination.
Signs and symptoms:
The early stages of cervical cancer may be completely asymptomatic (Canavan & Doshi, 2000). Vaginal bleeding, contact bleeding or (rarely) a vaginal mass may indicate the presence of malignancy. Also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced disease, metastases may be present in the abdomen, lungs or elsewhere.
Symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or feces from the vagina, and bone fractures.
Treatment:
Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the Lymph nodes are removed as well. An alternative for patients who desire to maintain fertility is a local surgical procedure such as a LEEP or cone biopsy.
If a cone biopsy was not able to produce clear margins, there is one possible option left for those with early stage cervical cancer who would like to preserve their fertility while treating their cervical cancer: a trachelectomy. For those in stage I cervical cancer, which has not spread, this is a viable treatment option. It allows for the preservation of the ovaries and uterus while surgically removing the cervical cancer. This treatment option is not yet well known amongst doctors and is not yet considered a standard of care. Furthermore, few doctors are trained in this fertility sparing surgical option. Even the most experienced surgeon won't be able to promise that this can be performed beforehand, as the extent of the spread of cervical cancer is unknown until surgical microscopic examination is completed. As a result, there is always the possibility for the need to convert to a hysterectomy if the surgeon is not able to microscopically confirm clear margins of cervical tissue once the patient is under general anesthesia in the operating room. This can only be done during the same operation if the patient has given consent for a possible hysterectomy prior to the operation. Due to the fact of the possible risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the womb. Once all the checks have been done and if all is well, the cervix will be stitched closed with a cerclage. This will allow for menstruation and fertilization but not dilation for a vaginal delivery, therefore requiring any future births are delivered by cesarean section. A radical trachelectomy is a smaller operation than hysterectomy, but more importantly allows for the preservation of fertility. This operation can also be performed vaginally instead of abdominally , however there are conflicting opinions as to which approach is better. A radical abdominal trachelectomy with lymphadenecectomy usually only requires a 2- to 3-day hospital stay with most women recovering very quickly (approximately 6 weeks). Complications are generally uncommon, although women who are able to conceive after surgery are prone to preterm labor or possible late miscarriage. It is generally recommended to wait at least one year before attempting to become pregnant after surgery. Recurrence in the residual cervix is a very rare event as long as the cancer has been cleared with the trachelectomy.[22] Even though recurrence is rare, it is generally recommended for patients to practice vigilant prevention and follow up care including pap screenings/colposcopy, with biopies of the remaining lower uterine segment as needed (every 3-4 months for at least 5 years) to monitor for any recurrance in addition to minimizing any new exposures to HPV through safe sex practices until one is actively trying to conceive.
Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and brachytherapy (internal radiation). For patients treated with surgery who have high risk features found on pathologic examination, radiation therapy with or without chemotherapy is given in order to reduce the risk of relapse.
Larger early stage tumors (IB2 and IIA more than 4 cm) may be treated with radiation therapy and cisplatin-based chemotherapy, hysterectomy (which then usually requires adjuvant radiation therapy), or cisplatin chemotherapy followed by hysterectomy.
Advanced stage tumors (IIB-IVA) are treated with radiation therapy and cisplatin-based chemotherapy.
On June 15, 2006 Food and Drug Administration approved the use of a combination of two chemotherapy drugs, Hycamtin and cisplatin for women with late-stage (IVB) cervical cancer treatment.Combination treatment has significant risk of neutropenia, anemia, and thrombocytopenia side effects. Hycamtin is manufactured by GlaxoSmithKline.