In Australia, cervical cancer has become less frequent. Approx 400 patients are diagnosed every year in Australia, which is a decline of 34% from 2002. This fortunate and very encouraging data are the result of the cervical (PAP smear) screening program that has been introduced to Australia some 20 years ago. We also hope that the cervical cancer incidence will further decline due to the effects of the vaccination program that has been established in 2007. Human Papilloma Virus (HPV) causes cervical cancer and smoking co-contributes to its development.
Typically, a PAP smear will pick up abnormalities on the cervix. However, a PAP smear will not ascertain a diagnosis of cervical cancer. The vast majorities of abnormalities detected by PAP smears are harmless or pre-cancerous. A biopsy of the cervix is required to determine if the abnormality is inflammation (benign), pre-cancer (CIN; Cervical Intraepithelial Neoplasia) or cancer.
CIN will require treatment if it is severe (CIN2 or CIN3). Excision requires day surgery and follow-up for 24 months. CIN1 requires follow-up only but not surgery. The chances that it disappears by itself is very high (>80%).
In contrast, cervical cancer requires instant action. After a diagnosis has been established by biopsy, the extent of disease needs to be explored. A CT scan of the pelvis, abdomen and chest or ideally a PET/CT will determine if the cancer has spread to local lymph nodes or anywhere else.
Small lesions that are limited to the cervix (stage 1) can be treated with surgery, whereas larger tumours or those extending beyond the cervix (stage 2 or higher) require a combination of radiotherapy with chemotherapy.
Surgical options need to include the primary tumour (cervix) plus the regional lymph nodes to which the cancer can spread. A negative PET/CT is only 85% accurate. Removal of lymph nodes increases the accuracy to 100%.
Surgery may include the following procedures:
- A cone biopsy to remove the cervix is sufficient for very small lesions (a few mm small). This procedure can be performed with or without surgical exploration of the pelvic lymph nodes (depending on other factors).
- A radical trachelectomy which involves removal of the cervix and the tissue next to the cervix (parametria). This procedure is mostly done in combination with a removal of pelvic lymph nodes. It can be performed for small (<3 cm) lesions and its aim is to retain the patients fertility.
- A radical hysterectomy is another option if fertility is not desired. The ovaries, which produce the hormones (oestrogen, progesterone, androgens) can be removed or preserved, depending on some factors. The procedure is often offered in combination with a lymph node removal and can be done laparoscopically (key hole) or through an abdominal incision (open).
Bowel preparation is not required. Please fast at least 6 hours prior to surgery. Please stop smoking before the operation as it makes your postoperative management much easier.
All procedures require general anaesthesia. For larger procedures that require an abdominal incision I encourage patients to have either an epidural catheter inserted or a pain catheter as these devices allow for appropriate pain control after the operation.
In case a radical trachelectomy or radical hysterectomy has been chosen, there is a small chance that I have to abandon the procedure if there is evidence of cancer spread to lymph nodes or to other organs in the abdomen. In such a case surgery is not recommended and radiotherapy becomes the treatment of choice, still aiming for cure.
When you wake up from anaesthesia there will be some lines running in and out of you for support. A drip will give you the necessary fluids, a catheter will drain the urine from your bladder and an epidural catheter will allow for adequate pain control. An oxygen mask will supply oxygen to the respiratory system. A drain may collect body fluid from the inside of the abdomen. These lines will be removed once I am happy that your body functions return to normal, which is usually after 24 to 48 hours. The catheter in the bladder will remain for at least 3-4 days because of the high chance of bladder dysfunction.
The final histopathological report may take a couple of working days. It forms the basis for the decision if any further treatment is required. In up to 15% of the patients postoperative radiotherapy is recommended to minimise the chance of cancer recurrence
Surgery always carries risks. Before surgery, we do everything in our power to minimise these risks. I give antibiotics before the skin incision in order to avoid skin and other infections. Prior to surgery all patients will have two types of stockings, which will prevent the formation of blood clots in the legs. At surgery sterile handling of instruments further reduces the risk of infectious complications. However, there are some immanent risks of surgery for cervical cancer, you should know about:
- Medical and anaesthetic risks associated with general anaesthetic, with epidural analgesia or with postoperative pain control do exist. In patients with pre-existing medical conditions these risks are obviously higher.
- There is a risk of injury to pelvic organs, such as the bowel, the bladder, the ureters, blood vessels and nerves. These injuries usually get repaired during surgery. However, in a small proportion of patients these injuries are not recognised during surgery or injuries may even develop after surgery. Then another operation is required to repair those defects. Injury to big blood vessels may result in need of blood transfusion. Injury of nerves is common in patients who require removal of lymph nodes in the pelvis. Many patients will experience some numbness of the skin around the upper thigh.
- Bladder dysfunction: Due to the required dissection of the tissue around the bladder and the ureters, the voiding sensation is disturbed. As a consequence most patients experience difficulties feeling a fullness of the urinary bladder resulting in voiding difficulties. Therefore a urinary catheter will stay in the bladder for up to 5 days. If the bladder dysfunction is still present after a week, the patient will be trained to perform self-catheterisation of the bladder. Bladder dysfunction beyond 4 weeks is extremely rare.
- Lymph oedema: Lymphatic fluid usually drains from the legs via the lymph glands in the pelvis and the aorta back into the blood circulation. When lymph glands have to be removed, some fluid may accumulate in the legs (lymph oedema). The risk of lymph oedema is around 20% in patients who had to have a lymph node dissection.
- If the ovaries were preserved, there is a risk in the range of 10 to 20% to develop ovarian cysts, which subsequently may require surgery.
Other possible complications include ...
- Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia
- Thromboembolic complications (formation of blood clots) in the legs that can even travel to the lungs and cause life-threatening emboli. This risk is very small because of our efforts to minimise them.
- A vaginal discharge that can even be blood-stained is very common for up to 6 weeks.
- Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that s needed for the surgery. It normally lasts only for a day but painkillers are not effective.
- Changes in bowel habits are not uncommon for a couple of months post surgery. I recommend regulation of the bowels with natural substances such as yoghurt, prune juice and natural fibre.
You need to stay in hospital for one or two days if the procedure was done laparoscopically or 6 to 8 days if a laparotomy (opening of the abdomen) was necessary. I recommend you have a good break for the two to four weeks. Especially I recommend avoiding intercourse, vaginal tampons and full baths and other factors that could disrupt wound healing or facilitate an infection.
Please notify me immediately if your condition becomes worse after you have been discharged from hospital.
If surgery is not possible (patients with stages 2, 3 or 4) a combination of radiotherapy with low dose chemotherapy is standard treatment. Radiotherapy is given on a daily basis and will be complemented by weekly chemotherapy doses. If this treatment is the best treatment available, I will refer my patient to appropriate specialists I work regularly with and who have a specific interest in the treatment of cervical cancer.
Following primary cancer treatment, you should be seen regularly for follow-up for at least 5 years. These examinations will include pelvic examinations and medical imaging if needed. Should you develop any bleeding or pain, please contact me immediately.
Cancers of all types and stages may recur. Recurrence may be local (vaginal), in the pelvis or at distant sites (abdomen, lungs). Treatment of recurrent cancer depends on the initial stage of the cancer (stages 1 to 4), the cell type of the cancer, the patient’s medical fitness and her wishes.
Survival rates for cervical cancer depend on its initial stage. Survival for stage 1 ranges between 75% and 95% at five years.