What is the cervix and what does it do?
The cervix is the bottom part of the uterus (womb), and is often called the neck of the womb. Its main function is to keep the uterus closed when a woman is pregnant, so the developing baby does not slip out. Your cervix can be seen when you have a pap smear, and can be felt when you have an internal examination by a doctor or nurse.
Cancer of the cervix can take many years to develop. Before it does, early changes occur in the cells of the cervix. The name given to these abnormal cells, which are not cancerous but may lead to cancer, is cervical intra-epithelial neoplasia (CIN). Some doctors call these changes precancerous, meaning that the cells have the potential to develop into cancer if left untreated. It is important to know that most women with CIN do not develop cancer. CIN may also be referred to as dysplasia.
Most women have regular cervical pap smears. The smear test is designed to detect early changes in the cells of the cervix, so that treatment can be given to prevent a cancer from developing. The aim of a smear test is to prevent cancer, but it can also sometimes detect a cancer that has already developed, before the patient develops symptoms.
The most common symptom of cervical cancer is abnormal bleeding, such as between periods or after intercourse. There may be a smelly vaginal discharge, and discomfort during intercourse. In women who have been through menopause (who have stopped their periods), there may be some new bleeding. These symptoms can also be caused by many other conditions, but it is important to see your doctor or nurse about them, even if you feel shy or embarrassed. The sooner you see your doctor and the diagnosis is made, the better the chance that treatment will be successful if it is cervical cancer.
If your smear is abnormal or your doctor is worried about the appearance of the cervix, you will most likely be sent for a colposcopy. In this test the cervix is washed down and any abnormal areas identified. Sometimes a small biopsy (sample of tissue) may be taken, but in other cases it may be more appropriate to perform a wider biopsy (called a cone or incision biopsy), which is done under general anaesthetic. At the same time you may have the inside of the bladder inspected (cystoscopy) and have the pelvis examined under anaesthesia (EUA).
There are two main types of cancer of the cervix. The most common is called squamous cell carcinoma, which develops from the flat cells covering the outer surface of the cervix (ectocervix). The second type is called adenocarcinoma, which develops from the glandular cells which line the inside of the cervical canal (endocervix). Some adenocarcinomas start in the cervical canal and may be more difficult to detect with smear tests.
The pathology report from the biopsy gives other important information, such as the grade (how abnormal or aggressive the cells appear under the microscope), and whether there are signs of cancer cells in the lymph or blood vessels, which may indicate potential early spread. Some of this information, in addition to the doctor’s physical examination and tests, will influence the advice you are given about the best type of treatment for you.
If the tests show that you have cancer of the cervix you will be sent to a gynaecologist specialising in the treatment of cancer, a gynaecological oncologist. You may have further tests to check your general health and see whether the cancer has spread. These may include blood tests, a chest X-ray and various scans (CT, MRI or PET). These test are painless and can give more information about any possible spread of the cancer.
The stage of a cancer is a term used to describe its distribution and whether it has spread beyond the cervix. Knowing the extent of the cancer helps the doctors to decide on the most appropriate treatment.
Cervical cancer is divided into four stages. Early cancer that is confined to the cervix is stage I. After this stage the cancer may spread into surrounding structures (stage II or III) or other parts of the body (stage IV). If the cancer has spread to distant parts of the body this is known as secondary cancer (or metastatic cancer).
The stages of cervical cancer are described below:
Stage I: The cancer cells are present only within the cervix.
Stage II: The tumour has spread into surrounding structures such as the upper part of the vagina or tissues next to the cervix.
Stage III: The tumour has spread more widely to surrounding structures such as the lower part of the vagina or to the sides of the pelvis. Sometimes a tumour that has spread to the pelvis may press on one of the ureters. This may cause a build up of urine in the kidney.
Stage IV: The tumour has spread to the bladder or bowel or beyond the pelvic area. This stage includes tumours that have spread into the lungs, liver or bone, although these are not common.
Grading refers to the appearance of the cancer cells under the microscope. There are three grades: grade 1 (low grade), grade 2 (moderate grade) and grade 3 (high grade). Low grade means that the cancer cells look very similar to the normal cells of the cervix. They usually grow slowly and are less likely to spread. In high grade tumours the cells look very abnormal or “angry”, and are likely to grow more quickly and spread.
In the early stages of cervical cancer, surgery is usually the first treatment. It has the advantages of: 1) fewer long term side effects, and 2) radiotherapy can be used after surgery at a later date if necessary. In some circumstances it is more appropriate to use radiotherapy with or without chemotherapy as the first treatment.
At the operation the uterus and cervix are removed with a margin of healthy tissue around the tumour. This is known as a radical hysterectomy. The lymph nodes are also removed to see if there has been any spread of the cancer. This component of the operation is known as a pelvic lymphadenectomy. The ovaries may or may not be removed (oophorectomy), depending on your age and the type of cancer in the cervix. A small portion of the upper vagina is removed as part of the surgical margin.
On some occasions, young women who wish to maintain their fertility and not have a hysterectomy may have a lesser operation. There are risks associated with this, and such an approach would only be offered by a trained cancer surgeon and only after extensive discussion with you.
At the completion of surgery, all of the tissue is then looked at carefully by the pathologist, a process which may take up to 1-2 weeks.
Occasionally, if there is evidence that the cancer has spread, you may be advised to have radiotherapy after surgery, with or without low dose chemotherapy, to decrease the chance of the cancer returning. This advice is individualised for every patient, and will be discussed with you in detail at the time.
Some early tumours and later stages are treated primarily with radiotherapy and chemotherapy, or with radiotherapy alone.
Radiotherapy treatment delivers high energy rays (similar to x-rays) to the cancer, or where cancer cells may be located. These rays come from an external source, which requires patients to come in to hospital for 5 days a week for up to 6-8 weeks. The treatment takes just a few minutes, and it is painless. Often internal radiotherapy is given as well, to deliver high doses of radiation to the cervix region. This is called brachytherapy.
Radiotherapy can also be used to ease the pain caused by metastases (cancer spread to other organs) and stop tumors from bleeding. Generally, doctors try to limit the amount of radiation that your vital organs receive, and avoid treating large portions of the bowel and pelvis, to reduce damage to healthy tissue.
Most patients who receive radiotherapy will also receive low dose chemotherapy on a weekly basis. One of the more commonly used drugs is called cisplatin. Its role is to make the radiation work more effectively, and potentially kill any cancer cells that may have spread outside of the pelvic region.
For patients whose cancer returns or those who are diagnosed with advanced cancer initially, chemotherapy may be offered by itself to help control symptoms. Again one of the more common drugs used is cisplatin.
Our team will also talk to you about being involved in the latest cancer treatment research. This generally involves a clinical trial, where you are offered either: 1) the best current treatment (known as the gold standard treatment), or 2) another combination of drugs that we believe is as good or better. The treatment you are offered is decided at random once you have read about the research and given consent to take part, so you have an equal chance of being offered either treatment. It is through such medical research that we have been able to advance cancer treatment.er. It is through medical research and clinical trials that we have been able to advance cancer treatment.
After treatment is completed, patients are monitored regularly to make sure the cancer has not returned. This involves 3 monthly visits to start with. Your doctor will ask you some questions and perform an examination, including a pelvic examination and a Pap smear from the top of the vagina.
CT scanning is not a routine part of follow-up care, but may be done if the doctor is unsure about their examination findings.
A Certified Gynaecological Oncologist (CGO) is a specialist gynaecologist who is trained in women’s cancer surgery. Patients whose surgery is undertaken by a CGO are more likely to have optimal debulking surgery and adequate staging, resulting in a greater chance of longer survival.