General information
Cervical cancer affects the lower part of the uterus, which connects the vagina to the endometrial cavity. It is a malignant disease with a very high rate of prevention. Moreover, if detected early, the prospects of cure are excellent.
Causes of cervical cancer
Cervical cancer usually affects women over 30 years old.
In the vast majority of cases (> 99%), it is the result of a chronic, active infection with aggressive types of human papillomavirus (HPV). Although HPV is the most common sexually transmitted disease, only a few women will eventually develop cervical cancer.
Risk factors for developing cervical cancer
HPV virus is almost always the cause of cervical cancer. Therefore, any factor that increases the likelihood of exposure to the virus or reduces the likelihood of treatment based on the body’s defense system contributes to the occurrence of cervical cancer. Risk factors include:
- The onset of sexual life at an early age
- Multiple and high-risk sexual partners
- Smoking
- HIV infection and any disease or drug (e.g., chronic use of corticosteroids) that suppress the body’s defense
- Perhaps, the long-term use of birth control pills
How can cervical cancer be prevented?
To lower the risk for cervical cancer, it is necessary to:
- Stop smoking
- Use condoms
- Limit the number of sexual partners
- Use HPV vaccines
- Schedule a regular gynecological check-up with PAP test and HPV test
What are the symptoms of cervical cancer?
In the very early stages, cervical cancer may not cause symptoms. Later, the patient may experience vaginal bleeding between her menstrual periods, menopause or, often, increased discharges after sexual intercourse. A gynecological examination is necessary, as these symptoms are not only related to cervical cancer.
How is cervical cancer diagnosed?
Depending on the size of the tumor, if it is visible during the gynecological examination, and the existence of symptoms, cervical cancer can be diagnosed with a PAP test or, directly, by taking biopsies, usually after colposcopy. Other times, it is identified in the preparation of conization (LEEP) which is performed for the treatment of precancerous lesions or the fullest investigation of suspected cervix when colposcopy is not satisfactory. In any case, histological examination will provide information about the type of tumor. The most common histological types are the squamous (70%) and adenocarcinoma (25%), while, very rarely, squamocolumnar, neuroendocrine (small cell) carcinoma, lymphoma and cervical sarcoma are found.
What should I do if I am diagnosed with cervical cancer?
If the cervical biopsy shows cancer, the next step for the patient is to visit a Gynecologic Oncologist, i.e., a Gynecologist with official individualization in gynecological cancers’ treatment. The Gynecologic Oncologist has all the necessary knowledge and technical skills to evaluate the patient, provide surgical treatment when appropriate and coordinate the rest of the treatment and subsequent follow-up.
Surgical treatment
How is the cervical cancer staging performed?
The staging of cervical cancer is an essential step in order to determine the extent of the disease and, therefore, select the appropriate treatment. In this context, the Gynecologic Oncologist needs to know the size of the tumor, whether it extends to the tissues adjacent to the cervix (adnexa, vagina, bladder, lower part of the colon or other parts of the pelvis) and the possible existence of lymph nodes or distant (e.g., pulmonary, hepatic, bony) metastases. In order to obtain the above information, the following steps are necessary:
- Gynecological examination, including a digital rectal examination,
- Magnetic Resonance Imaging (MRI) of the lower abdomen with intravenous contrast agent,
- PET/CT or alternatively chest CT and upper abdomen CT or MRI with intravenous contrast agent,
- Rarely, cystoscopy and/ or orthoscopy,
- Other examinations, based on the doctor’s judgement.
What is the basis of surgical treatment at the initial stages of cervical cancer?
In the early stages of the disease, surgical treatment is possible. The scope of the surgery is determined by the stage of the disease, based on the findings of the preoperative monitoring and the patient’s desire to have children in the future. The classic surgical treatment of cervical cancer involves a radical hysterectomy, during which the uterus, cervix, tissues surrounding the uterus (adnexa) and the upper part of the vagina are removed. However, at an incipient disease, cervical conization or total hysterectomy (i.e., without removing the adnexa and upper part of the vagina) are considered perfectly acceptable options. It is noticed that the surgical removal of the ovaries is not necessary in cervical cancer and especially in the squamous type, if a woman wants to avoid early menopause. If the patient wishes to maintain her fertility, read more details about the surgical treatment options here.
What is the role of lymphadenectomy?
Depending on the size of the tumor and the depth of cervical filtration, the risk of lymph node metastases varies. At early disease detection, without the presence of lymphovascular invasions (LVI), lymph node removal is not recommended. In other cases where the disease is considered operable, the pelvic removal (common, internal and external iliac and thyroid lymph nodes) and, more rarely, paraortic lymph nodes may be required. If there are swollen lymph nodes in the scan images or intraoperatively, their excision is necessary. Finally, when the conditions are satisfied, the investigation of lymph node metastases with the sentinel node biopsy contributes to their diagnosis, significantly reducing the complications of complete lymph node dissection (e.g., lymphedema, lymphocysts).
How is surgery performed on patients with cervical cancer?
Total hysterectomy in patients with cervical cancer can be performed openly or with minimally invasive surgery techniques (laparoscopy, robotic surgery). Although the latter options are associated with a reduced risk of wound infection or bleeding and lead to faster recovery, recent data has shown that open surgeries may be linked to better oncological results. On the other hand, when total hysterectomy is sufficient to treat the disease, robotic surgery and laparoscopy appear to be advantageous under certain conditions.
Is there a treatment if the disease is inoperable?
In cases where the patient with early-stage disease cannot undergo surgery or in the more advanced stages of the disease, the treatment of cervical cancer includes radiotherapy (external and intravaginal), usually in combination with chemotherapy.
Adjuvant therapy
What additional treatments may the patient need after cervical cancer surgery?
The administration of adjuvant therapy after surgery is determined by the possibility of recurrence of the disease. The presence of large tumors, the deep filtration of the cervical wall thickness, the presence of lymphovascular invasions (LVI), the filtration of the adnexa or the surgical boundaries and metastases in the lymph nodes are among the factors that increase it. The respective decisions must be taken in an Oncology Council, with the participation of a Gynecologist Oncologist, a Pathologist Oncologist, a Radiotherapist and a Pathologist.
In cases where additional treatment is needed, the options are:
- Intravaginal radiotherapy (brachytherapy)
- External radiotherapy. It is administered for five days per week and lasts a total of 5-6 weeks.
- Chemotherapy. It usually involves cisplatin administration on a weekly basis, for the duration of external radiotherapy. In this context, chemotherapy works by increasing the toxicity of radiotherapy to cancer cells.
What are the main side effects of radiotherapy?
Radiotherapy may cause urination disorders (e.g., frequent urination, pain in urination), bowel disorders (for example diarrhea), fatigue and changes in the vagina (for example shortening, narrowing, dryness). Some of them subside at the end of treatment, while other symptoms may persist for longer.
How does cervical cancer treatment affect the patient’s sex life?
The removal of the ovaries in premenopausal women and, above all, radiotherapy can lead to changes in the vagina that affect the quality of sexual life. To mitigate the effects, the use of vaginal gel with lubricating and moisturizing effect, as well as vaginal dilators, is recommended. Counseling by individualized sexologists can also be very helpful.
What is included in follow-up care upon completion of treatment?
Follow-up care after treatment is based on:
- Periodic clinical examination, including gynecological examination,
- Annual PAP test,
- Periodic screening tests. The available options include computed tomography or magnetic resonance imaging and PET/CT, so the relevant decisions are made based on the doctor’s judgment and the symptoms that the patient may have.
