Cervical Cancer

The cervix is at the top of vagina and lies at the lower part of womb. Infection by human papillomavirus (HPV) (a family of viruses that infect the skin and mucosal membranes lining the body) may cause abnormal changes to the cells of the cervix, a condition called Cervical Intraepithelial Neoplasia (CIN).  CIN is not cancer, but there is a chance that it may develop into cancer.

Women with these conditions are more susceptible to cervical cancer:

• Persistent HPV infection, especially by HPV types 16 and 18, increases the risk of CIN
   
• Have had sex before, especially if started at an early age
  
• Sexually transmitted diseases
  
• The higher the number of sex partners a woman or her partner has, the greater the risk of cervical cancer
  
• Weakened immunity, chronic renal diseases, AIDS or other immune system diseases
  
• Tobacco smoking
  

The following ways can help prevent cervical cancer:

• Quit smoking
  
• Beware of personal hygiene. Practice safer sex. Consistent use of condom can help reduce the chance of HPV infection or other sexually transmitted diseases
  
• Regular cervical cancer screening (also known as “Pap test”) can reduce the chance of cervical cancer by 90%. Screening should be done once every year at the beginning and after two consecutive normal results, once every three years thereafter
  
• Cervical cancer vaccination
  

70% of cervical cancer is caused by two HPV subtypes, namely, HPV 16 and 18. Genital HPV is mainly transmitted by sexual contact. Persistent HPV infection of the cervix may lead to CIN. After a long period of time, it may develop into cervical cancer.

CIN
CIN is not cancer. It is a condition before the occurrence of cancer. There are three types of CIN.

• CIN 1 – abnormal changes involving only 1/3 of the thickness of the skin covering  the cervix
    
• CIN 2 – 2/3 of the thickness of the cervix is involved
    
• CIN 3 - full thickness of the cervix is involved

If CIN 3 is not treated properly, the chance of it developing into cancer in 10 years is about 40%.

    Cervical cancer in its early stage may not present any symptoms at all. If you notice the following, you should consult your doctor and undergo examinations as soon as possible:

• Abnormal vaginal bleeding
  
• Bleeding between periods or after sexual intercourse
  
• Vaginal bleeding after menopause
  
• Blood-tinged vaginal discharge

Other symptoms include:

• Foul smelling vaginal discharge
  
• Backache, swollen feet or difficulty in passing stool may occur in the advanced stage of cervical cancer
  

If cervical cancer is suspected after history taking, the doctor would arrange for the following examinations:

Cervical cancer screening or “Pap smear test”: a non-distressful procedure requiring only a few minutes. Follow-up procedures will be necessary if abnormal changes or cancerous cells are detected.

Colposcope: examination and evaluation of any tumor in the cervix

Cervical biopsy: if tumor is found in the cervix during examination, a tissue sample will be taken and sent for pathology test.

Blood tests, X-ray and various scans: to determine the area affected by cancer and guide treatment strategies.

Cervical cancer has 4 stages:

Stage I – cancer cells have intruded to subcutaneous tissue (that lies beneath the skin) but remain confined to the cervix uteri.

Stage II – cancer cells have spread to the tissues around the cervix or top of vagina.

Stage III - cancer cells have spread to the sides of pelvic cavity or 1/3 of the lower part of vagina.

Stage IV – cancer cells have spread to other major organs, e.g. bladder, large intestine or lungs.

    Doctor may suggest the following treatments for cervical cancer:

(1) Surgical treatment
Apart from the tumor in the cervix, the womb, part of the vagina, tissues around the womb and lymphatic tissues nearby are also removed.  Age of the patient will be considered to decide on the removal of the ovaries.

(2) Radiotherapy
There are two types of radiotherapy, external radiotherapy and internal radiotherapy. They are usually used together for the best result.

• External radiotherapy – using linear accelerator to deliver high-powered radiation beams to the tumor sites and the whole pelvic cavity to eradicate the tumor.

• Internal radiotherapy – this procedure is conducted in the operating room when the patient is under general anesthesia. The doctor will insert a small apparatus into the patient’s vagina and cervix, through which radiation is emitted for treatment. Patient usually needs to undergo 3 to 4 times of treatment with 10 to a few dozen minutes for each time.

Potential side effects of radiotherapy:

• Diarrhea and fatigue
  
• Bleeding of the bladder or rectum
  
• Narrowing of the vagina

(3) Chemotherapy
Chemotherapy helps to shrink the tumor and is complementary to radiotherapy to enhance the effect. Intravenous chemotherapy, that is injection of the drug through a vein, is usually used.

When chemotherapy is carried out with radiotherapy, it leads to a decrease in the patient’s blood count, resulting in fatigue and susceptibility to infection.  Patient may need administration of anti-biotics and those with anemia may need blood transfusion.

Surgical treatment and radiotherapy have the same effect for Stages I and II cervical cancer. But for younger patients in better health conditions, surgical treatment is preferred to salvage the ovaries for the reproductive hormones. It may also lower the impact on sex life related to the narrowing and hardening of vagina as a result of radiotherapy. The long-term effect of surgical treatment is less than that of radiotherapy.

For cervical cancer in later stage, radiotherapy and adjuvant chemotherapy are the main treatments.

Complications that may occur during surgical treatment for cervical cancer:

• Damages to major blood vessels during surgery causing massive bleeding. The condition can be life-threatening.

• Damages to the bladder, rectum, ureter (the tube from the kidneys to the bladder) and nerves. Patients may need another operation if necessary.

Potential adverse effects after surgery:

• Difficult to urinate

• Edema (fluid retention causing swelling of the affected area) of lower limbs, mild numbness to the thighs

• Lymph accumulating in the pelvic cavity causing lymphocele (a large, cystic mass filled with lymphatic fluid) and subsequently infection

• Bleeding or hematocele (collection of blood) of vagina, wound infection

• Unable to be pregnant

Patients would be physically weaker after treatment. Ways to enhance recovery and strengthen immunity include:

• Becoming physically active as soon as possible
   
• Adequate rest and exercise: e.g. walking, calisthenics, tai chi, qigong, etc.
  
• Quit smoking and alcohol
  
• For diet, one should:
  
• Avoid food that is spicy, preserved or high in fat
  
• Diet high in protein and vitamins. Intake of fresh fruits and vegetables to  facilitate bowel movement      

• Sex life: patients should restrain from sex during the first 6 weeks after surgery to allow time for healing of the wound. Sex may be resumed after the body has fully recovered