What is Cervical Cancer?
Cervical cancer is the growth of abnormal cells within the cervix. The cervix is the lower part of the uterus that connects to the vagina. In Australia, approximately 900 patients are diagnosed every year.
There are two main types of cervical cancer: squamous cell carcinoma (SCC), which begins in the squamous cells of the cervix; and Adenocarcinoma which develops in the glandular cells of the cervix.
Cervical cancer is one of the most preventable types of cancer due to Australia's cervical cancer screening and vaccination program. Most early-stage cervical cancers come with high survival rates.
Cervical Cancer Causes
Almost all cervical cancers are caused by an infection with the sexually transmitted human papilloma virus (HPV).
If the body does not clear the infection and it becomes persistent, high-risk HPV types can cause changes to cells in the cervix which may develop into cervical cancer. Only a small proportion of women with HPV go on to develop cervical cancer.
There are also some people who are at higher risk of developing cervical cancer. Other risk factors for cervical cancer include:
- Lack of cervical cancer screening tests
- Previous abnormality of the cervix
- Younger age
- Long-term use of the contraceptive pill
- Diethylstilboestrol (DES). DES is a synthetic form of the hormone estrogen. Doctors prescribed DES to help some pregnant women to prevent miscarriage between the 1940s and 1970s in Australia. Women whose mothers were given DES during pregnancy may be at increased risk of rare types of cervical cancer.
Although certain factors can increase a woman's risk for developing cervical cancer, they do not necessarily always cause the cancer.
Cervical Cancer Screening Program
In Australia, women aged 25 to 74 years of age are advised to have a cervical cancer screening test every 5 years. Cervical screening aims to check for the presence of HPV.
Australia transitioned from a PAP smear system to a HPV-based system in 2017 because the previous system failed to detect certain types of cervical cancer. The new HPV-based system is superior and more reliable.
HPV Vaccination Program
Since 2007 in Australia, you can also be vaccinated against HPV, reducing the risk of both infection and cervical cancer. This vaccine provides more than 90% protection against cancer of the cervix. It reduces the risk not 100% but almost completely.
Cervical Cancer Symptoms
Patients with cervical cancer often develop no symptoms when the cancer is in its precancerous and early stages. For this reason, regular cervical cancer screening is important. Screening picks up early stages of cancer when there are no symptoms yet.
With local tumour spread, cancer of the cervix can cause symptoms that may include:
- Vaginal bleeding between periods (spotting)
- Vaginal bleeding after menopause
- Menstrual bleeding that is heavier or longer than usual
- Pain during or bleeding after intercourse
- Unusual vaginal discharge
- Pain when urinating.
It is important to see your GP in the first instance for a women’s health check if you have one or more of these symptoms, or if these symptoms are persisting.
Diagnosing Cervical Cancer
If your cervical cancer screening returns a positive test result for HPV, the pathology laboratory automatically conducts further testing on the same sample to determine if abnormal cells (Cervical intraepithelial neoplasia; CIN) are present. If both HPV and abnormal cells are present you will need to see a gynaecological specialist.
If you return positive test results for HPV with no abnormal cells present, you will be asked to return for cervical cancer screening in 12 months. Most peoples’ immune systems will clear the HPV within that time. If the HPV is still present after 12 months you will be referred to see a gynaecological specialist.
If you need to see a gynaecological specialist it means that a colposcopy is required. It is a procedure to look closely at the cervix, vagina and vulva to help locate changed or abnormal cells and see what they look like.
During a colposcopy you will lie on your back and the doctor will use a speculum to open the vagina so they can look at your cervix, vagina or vulva through a magnifying instrument (the colposcope) that has a light and resembles a microscope on a stand. The examination requires staining of your cervix, vagina or vulva with special solutions that may cause a mild stinging sensation. Sometimes, a biopsy should be taken to test some tissue from the surface of the cervix, vagina or vulva. A colposcopy generally takes 10 to 15 minutes. The results of the biopsy are usually available within a week.
The biopsy of the cervix is to determine if the suspected abnormality is inflammation (benign), pre-cancer (CIN) or cancer.
Cervical intraepithelial neoplasia (CIN)
Cervical intraepithelial neoplasia (CIN) is a precancerous condition in which abnormal cells grow on the surface of the cervix.
CIN1 often requires follow-up only but not surgery. The chances that it disappears by itself is very high (over 80%). Patients will require treatment if it is moderate to severe (CIN2 or CIN3). A limited excision (a LLETZ procedure) means day surgery and follow-up for 24 months.
If the biopsy shows cervical cancer this will require instant action to determine the extent of disease. This can be done through multiple imaging tests and sometimes also through a clinical examination under anaesthetic. A MRI will determine if the cancer has spread into tissues next to the cervix, whereas a PET/CT will determine if the cancer has spread elsewhere in the body.
Cervical Cancer Treatment
Cervical cancer that is 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 removal of the primary tumour located in the cervix plus the regional lymph nodes to which the cancer can spread.
Unfortunately we cannot be 100% sure if the cancer has spread to the regional lymph nodes using medical imaging. A negative PET/CT scan is only 85% accurate. Removal of lymph nodes increases the accuracy to 100% certainty.
Surgical treatment may include the following procedures:
- A cone biopsy to remove the cervix is sufficient for very small tumours (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 is the treatment of choice for women who still require fertility. It 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 only be performed for tumours less than 3 cm in largest diameter. It preserves the uterus for fertility reasons.
- 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, including the patient's age. The procedure is often offered in combination with a lymph node removal and should be done through an abdominal incision (open).
Prior to surgery
Bowel preparation is not required. Please fast 6 hours prior to surgery (nothing to eat or drink). Please stop smoking before the operation as it makes your postoperative management much easier.
All surgical procedures require general anaesthesia. For larger procedures that require an abdominal (open) incision, I encourage patients to have either an epidural or pain catheter inserted as these devices allow for appropriate pain control after the operation.
If a radical trachelectomy or radical hysterectomy has been performed, there is a small chance that I may 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 surgery a drip will provide the necessary fluids and a catheter will drain the urine from your bladder. 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 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 up to two weeks because of the high chance of bladder dysfunction.
Patients need to stay in hospital for 4 to 5 days. At discharge, I recommend to "take it easy" for 2 to 4 weeks. 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.
The final histopathological report may take up to a week. It forms the basis for the decision if any further treatment is required.
Surgery always carries risks and may include:
- Medical and anaesthetic risks associated with general anaesthetic, with epidural analgesia or with postoperative pain control.
- There is a risk of injury to pelvic organs, such as the bowel, bladder, ureters, blood vessels and nerves. Should this occur, these injuries usually get repaired during surgery. However, in a small proportion of patients these injuries can unfortunately not be recognised during surgery or injuries may even develop after surgery. If this should occur, then another operation is required to repair those injuries. Injury to large 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. In this case, 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 emptying difficulties. Therefore a urinary catheter will stay in the bladder for up to 2 weeks. If the bladder dysfunction is still present afterwards (hardly ever the case), the patient will be trained to perform self-catheterisation of the bladder. Bladder dysfunction beyond 4 weeks is extremely rare.
- Infections to the bladder, the abdominal wound, the lungs with resulting temperatures and septicaemia. I give antibiotics before the skin incision in order to avoid skin and other infections.
- Shoulder tip pain is common after laparoscopic surgery. It is caused by the CO2 gas that is needed for the surgery. It normally lasts a day but painkillers are unfortunately not effective.
- Thromboembolic complications (formation of blood clots) in the legs that can travel to the lungs and cause life-threatening emboli. Prior to surgery all patients will have two types of stockings, which will help prevent the formation of blood clots in the legs.
Possible complications in the weeks following surgery
- A vaginal discharge that can even be blood-stained is very common for up to 6 weeks.
- Lymphoedema: 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 are removed, some fluid may accumulate in the legs (lymphoedema).
- 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.
- If the ovaries were preserved there is a risk of developing ovarian cysts (approximately 10-20%), which subsequently may require surgery.
Radiotherapy and Chemotherapy
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 daily and will be complemented by weekly chemotherapy doses. I refer patients to radiotherapy and chemotherapy specialists who I regularly work with and who have a specific interest in the treatment of cervical cancer.
Following cancer treatment, you should be seen regularly for follow-up for at least 5 years. After five years, the risk of a recurrence becomes very low. These examinations will include pelvic examinations and medical imaging if needed. Should you develop any bleeding or pain, please contact me immediately.
Cervical Cancer Outcomes
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. In 2012–2016, individuals diagnosed with cancer of the cervix had a 74% chance of surviving for five years.