Cervical cancer starts in the cells that line the lower, narrow part of the uterus. It is one of the most commonly diagnosed cancers. However, women who regularly get a Pap test (cervical smear) are often diagnosed and treated on time. This cancer usually grows slowly and the vast majority of women treated recover completely.

Cervical cancer is the leading cause of cancer death, both men and women, in several countries in Africa and Latin America. 500,000 new cases are diagnosed each year worldwide.

According to the Centers for Disease Control and Prevention, 12,831 new cases of Cervical Cancer were diagnosed in 2017. 4,207 died from the disease.

According to the World Health Organization, the death rate from cervical cancer was 1 in 100,000 people in Canada, compared to 31 in 100,000 in Bolivia.

Cause of cervical cancer

Cancer of the cervix is ​​caused by a sexually transmitted infection (STI) that originates from the human papillomavirus (HPV). There are over 100 strains of the virus in the HPV family, some of which are more easily transmitted than others.

HPV infections are very common. In the majority of cases, the infection is controlled by the immune system and the virus is eliminated, with no further consequences for the body. In some women, the virus causes genital warts (condylomas) on the vulva, in the vagina or on the cervix. Doctors often have to treat these warts to help the immune system clear the virus. More rarely, the virus persists for years and turns the cells that line the cervix into precancerous cells and then into cancer cells. These then multiply at an uncontrolled rate and give rise to a tumor.

Two types of cervical cancer

80 to 90% of cervical cancers start in squamous cells, cells that look like fish scales and line the bottom of the cervix. This type of cancer is called squamous cell carcinoma.

10-20% of cancers start in the mucus-producing glandular cells found in the upper part of the cervix. This type of cancer is called adenocarcinoma.

Symptoms of cervical cancer

The most common symptoms of cervical cancer are bleeding that occurs independently of normal menstrual or post-menopause, or smear bleeding, for example after sexual intercourse. Persistent discharge from the vagina as well as constipation or pain during urination and bowel movements may also indicate cervical cancer. In addition, pain in the cruciate and pelvic area or an unexplained weight loss may be possible warning signs.

When the cancer is more advanced, the following symptoms may appear:

• Vaginal bleeding after sex, between periods or after menopause.
• Heavier or longer periods.
• Foul-smelling vaginal discharge.
• Pain during sex.
• Pain in the pelvis or lower back.

Risk factors of cervical cancer

• Neglecting to have a regular Pap test.
• Have sex at a young age.
• Having sex with multiple partners, or with people who have multiple sexual partners.
• To smoke.
• Not protecting yourself during sex.
• Having a weakened immune system, for example because of HIV or because of taking immunosuppressive drugs, for example.
• Having contracted other sexually transmitted diseases.
• Having taken diethylstilbestrol (DES) or have a mother who took DES–a drug prescribed between 1940 and 1971, especially for women who had repeated miscarriages. This risk factor is very rare today.

Diagnosis

In a speculum examination, the gynecologist can examine the vagina and the cervix and check for changes. Furthermore, the consistency and mobility of the cervix can be assessed by a touch examination. With the help of a special ultrasound probe, which is inserted into the vagina (transvaginal ultrasound), the uterine body as well as the ovaries can also be examined. This allows your doctor to get the first clues as to the presence of a disease.

In addition, a so-called colposcopy is usually performed. This is an examination with a special examination microscope, with which the surface of the cervix can be enlarged. This allows even the smallest changes of superficial cells to be detected. This examination will allow your doctor to determine whether there is evidence of malignant disease.

In addition, the cell smear examination (so-called PAP test) represents an essential step in the detection of cervical cancer or its precursors. Superficial cells are taken from the cervix with a small brush or spatula and examined microscopically in the laboratory. In this way, deviations from the normal cell image can be detected. This test is usually performed once a year at the gynecologist..

If the PAP smear provides a conspicuous finding, it may be useful to check for the presence of a human papillomavirus (HPV) infection. This infection is one of the most common sexually transmitted viral diseases. There are various virus subgroups, some of which are linked to cervical cancer. However, a positive test result alone is not yet a cause for concern. However, in combination with the gynecological findings and the result of the PAP smear, it can help to estimate the risk of cervical cancer individually.

If there is a suspicion of a precursor or manifest cancer due to the clinical or cytological findings, the cells of the cervix must ultimately be assessed in a fine-tissue manner in order to secure the diagnosis. For this purpose, a tissue sample (biopsy) is taken from the conspicuous site with a small, special pliers and examined under the microscope. In this way, the so-called histological findings are obtained, which can confirm the diagnosis and at the same time provide information about the severity of a precursor or what type of cervical cancer it is. The tissue sample is usually taken on an outpatient basis. Local anesthesia is not usually required.

As an alternative to biopsy, a small surgical procedure can performed in some cases for histological diagnosis. This is necessary, for example, if there is a suspicion of cervical cancer due to discomfort or certain preliminary findings, but no visible changes are found because they may be in the invisible cervical canal. In these cases, it is not possible to take a targeted tissue sample. In a so-called diagnostic conization, a conical piece of tissue is cut out of the cervix and subsequently assessed histologically. The cervix is scraped out with a special instrument and the mucous membrane is then examined.

If the suspicion has been confirmed and the diagnosis of cervical cancer has been made, it is important to know what stage of the disease you are in – that is, how large the tumor is, how far the cancer cells have spread and whether other organs or lymph nodes may also be affected. The necessary examination steps are summarized in medicine under the term staging. They are important so that your doctor can create an optimal treatment plan for you individually.

Today’s usual examination steps usually include computed tomography (CT) of the chest and abdominal cavity. Recently, a so-called PET (positron-emission tomography) is often performed in this situation. In this examination, a marker substance is injected into the vein in addition to the normal CT. This then accumulates in metabolically active tissue, i.e. also in tumor tissue, and is color-coded in the CT. In addition, in most cases, an MRI (magnetic resonance imaging) examination of the pelvis is performed in order to be able to more accurately assess the size of the tumor and its relationship to the adjacent organs and in particular an ingrowth in the pelvic connective tissue. An MRI scan of the pelvis takes about 30 minutes and is usually associated with no inconvenience. If there is a suspicion that the bladder and/or rectum are affected, bladder or intestinal mirroring is recommended.

If, after these studies, there is a suspicion that the cancer cells have spread to other organs, the doctor will decide individually whether further organ-specific examinations are necessary.

In addition, a blood test is one of the necessary steps to estimate the general state of health and organ functions. So-called tumor markers are often tested for. Tumor markers are molecules that are often formed by tumors themselves or whose concentration in the blood can be related to tumor diseases. With regular monitoring, they can above all provide information about the course of the disease during therapy or help to detect a recurrence at an early stage.

Once all examinations have been completed, your doctor will tell you which stage of the disease you are at and what therapeutic steps can now be taken.

The stages of cervical cancer

Cervical cancer be categorized in four different stages, depending on the size or extent of the tumor and whether other organs are also affected. Roughly, the stages of cervical cancer can be summarized as follows:

• Stage I: The tumor is limited to the uterus.
• Stage II: The tumor has grown into the surrounding connective tissue, but not up to the pelvic wall, and/or it has grown into the vagina, but the lower vaginal third is free.
• Stage III: The tumor has spread to the pelvic wall and/or affects the lower third of the vagina.
• Stage IV: The tumor has spread to the bladder or rectum or has grown beyond the boundaries of the small pelvis. If daughter tumors (metastases) are found in other organs, it is also categorized as stage IV.

Prevention of cervical cancer

Cervical cancer is a serious illness. When discovered and treated early, the likelihood of recovery is significantly better. All women should therefore be tested regularly.

• Get tested

Before they become cancerous, cells change in appearance. This precancerous condition is called cervical dysplasia. Getting a regular Pap test can detect precancerous cells. The doctor can then monitor their progress. If necessary, he or she can give treatment to prevent the cancer from developing.

If the cancerous stage has already occurred by the time of the Pap test, early detection will increase the chances of survival. It could also decrease the treatment time and the recovery period. According to a 2009 study in Canada, women who do not have a Pap test regularly are almost 3 times more likely to develop invasive cervical cancer than those who do.

The Pap test is easy and painless. Cells from the cervix are removed by rubbing with a small brush. They are then examined under the microscope.

Young women are recommended to have a Pap test soon after their first sexual encounter and no later than the age of 21. Depending on the results, the test is repeated at an interval of 1 year to 3 years, even if you have stopped having sex. This is because the HPV virus can survive for years on the cervix before leading to the formation of cancer cells.

• Wear condoms

It is estimated that about 75% of the population will be infected at some point in their life with the human papillomavirus (HPV). Until the vaccine was introduced, the only way to be sure against the strains of HPV that cause cervical cancer was to abstain from sex completely. Wearing a condom reduces the risk of transmitting HPV, but it only offers partial protection since it does not cover the entire genital area.

• Get Vaccinated

Since 2006, 2 vaccines against HPV strains that cause cervical cancer have been marketed: Gardasil and Cervarix. The vaccine protects against the 4 most common types of HPV which together cause 70% of all cervical cancers It also reduces the risk of getting warts.

Although the vaccine protects against future HPV infections, it has no effect on HPV infections that have already been acquired. Thus, the vaccine is especially indicated for young girls who have not yet started their sexual life and who have therefore not yet been exposed to the virus.

The vaccination is often administered in 3 doses over a period of 6 months. Since vaccination is not 100% effective, it does not exempt women from having a Pap test. The vaccine should be viewed as a complement to other preventive measures and not as a substitute for sexually transmitted infections.

Treatment of cervical cancer

The two basic treatments for cervical cancer are surgery and radiotherapy. Radiotherapy is almost always combined with chemotherapy.

The aim of the surgery is to completely remove the entire tumorous tissue. If all cancer cells can be removed, this creates the best conditions for a long-term cure. Therefore, it makes sense to perform surgery especially in the early stages of the disease. Which surgical method is optimally applied and the extent of the operation depends primarily on the spread of the tumor.

Radiotherapy is an integral part of the treatment of cervical cancer. It is used when it is not possible to perform surgery (e.g. due to the state of health) or if it does not seem reasonable due to large tumor spread. It can also be used after surgery to support long-term healing success (adjuvant radiotherapy). The aim of radiotherapy is to destroy cancer cells and prevent their spread. For this purpose, high-energy (ionizing) rays are directed at the tumor, which attack the nucleus of the cancer cells – thus they can no longer divide and die. Irradiation takes place over a certain period of time in several individual sessions, with the individual treatments lasting only a few minutes each and generally not painful. Your doctor will inform you about the side effects that may occur and may help you alleviate them.

In almost all cases, radiotherapy is combined with chemotherapy to further improve the chances of recovery. This treatment is called chemoradiotherapy. The aim of chemotherapy is also to stop cancer cells from growing, to damage them and to achieve a regression of the tumor. The active ingredients used for this purpose (so-called cytostatics) mainly attack those cells that divide particularly quickly. This primarily harms the tumor tissue. However, rapidly growing healthy cells are also attacked, which usually causes undesirable side effects. Ask your doctor what side effects are likely to happen and discuss with him the ways to alleviate them.

What treatment is right for you

The treatment options that are specifically available to you depend primarily on the stage of the disease you are at and how well your general health is. Your age and any desire to have children are also included in the individual therapy decision.

As a rule of thumb, several physicians from different disciplines (e.g. gynecology, oncology, radiotherapy) are involved in the planning of the exact therapy strategy. This collaboration of different experts is called a tumor board review in medicine. The aim is to ensure that all important factors are taken into account and that the optimal treatment options are found for you individually.

In the early stages of cervical cancer, the most important form of therapy is the surgical removal of the entire tumor tissue. Depending on the size of the tumor, the appropriate surgical method is chosen individually. Smaller tumors can often be removed by conization. If a conization is not sufficient to remove the entire tumor tissue, a so-called trachelectomy can be used in some cases. A large part of the cervix is surgically removed, but the uterus and the top 5 mm of the cervix are left in the body.

In the case of larger tumors, the entire uterus with adjacent connective tissue usually needs to be surgically removed – this procedure is called radical hysterectomy. Various surgical techniques are available for this purpose. Your doctor will inform you which method is most appropriate in your case. If the cancer cells have also spread to surrounding tissue or other organs, these may also be partially or completely removed. Your doctor will tell you whether it makes sense to perform an operation in your case, which method is appropriate and what individual advantages and disadvantages you have to reckon with. He or she will also help you make the right decision.

Performing radiation or radiochemotherapy after surgery can further increase the chances of long-term healing, but is also associated with more side effects.

In advanced stages of cervical cancer, it usually does not make sense to perform surgery. In these cases, radiation or chemoradiotherapy is primarily used to stop tumor growth and prevent further spread of cancer cells. This form of treatment is also effective at higher tumor stages and can make a significant contribution to prolonging survival and improving quality of life.

In conclusion

Although its incidence is decreasing, cervical cancer remains a common health problem. It usually takes a few years between the appearance of precancerous cells in the cervix and the development of cancer. During this time, there are usually no symptoms. Only a regular gynecological examination by a doctor will reveal these abnormal cells. This can be treated BEFORE the cancer starts.

Treatments for cervical cancer are evolving and success rates are gradually improving. Your doctor will be able to determine the best treatment for you. Do not hesitate to discuss your concerns and fears with him or her.