Cervical | Chris O'Brien Lifehouse

This information has been prepared to help you understand more about cervical cancer.

Many people feel understandably shocked and upset when they are told they have cervical cancer. This information is intended to help you understand the diagnosis and treatment of this type of cancer.

We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.

The cervix

The cervix is the bottom part of the uterus (womb), and is often called the neck of the womb. Its main function is to hold the developing baby in the uterus during pregnancy. The cervix can be seen during a Pap smear, and can be felt during internal examinations by a doctor or nurse.

The cervix has many functions, including:

  • producing moisture to lubricate the vagina
  • producing mucus that helps sperm travel up to the Fallopian tube to fertilise an egg from the ovary
  • holding a developing baby in the uterus during pregnancy
  • widening so the baby can pass down into the birth canal (vagina).

What is cervical cancer?

Cancer of the cervix can take many years to develop. Before it does, early changes occur in the cells of the cervix. 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 abnormal cells do not develop cervical cancer.

There are two main types of cervical cancer:

  • Squamous cell carcinoma: the most common type, accounting for 80% of all cervical cancers. It starts in the thin, flat cells covering the outer layer of the cervix (ectocervix).
  • Adenocarcinoma: a less common type of cervical cancer, which starts in the glandular cells that line the inside of the cervical canal (endocervix). This type is more difficult to diagnose because it develops higher in the cervical canal and is more difficult to reach with the brush or spatula used in a Pap smear.

How common is it?

If you would like to read any facts or statistics about bladder cancer, please refer to the Cancer Institute NSW website:

http://www.cancerinstitute.org.au/cancer-in-nsw/cancer-facts/cervical-cancer

The main known cause of cervical cancer is an infection called human papillomavirus (HPV). As well as HPV, some other factors will increase you risk of cervical cancer:

Human papillomavirus (HPV)

HPV is a very common group of wart viruses and around four out of five women will become infected with a genital type of HPV at some time in their lives. Many women will not know that they have it and, in most cases, it will clear up on its own.

Most women who have the HPV infection never get cervical cancer. Only a few types of HPV result in cervical cancer.

Smoking

Chemicals in tobacco can damage the cells of the cervix and make cancer more likely to develop.

Diethylstilbestrol (DES) exposure

DES is an oestrogen-based medication that was used to prevent miscarriage from the 1950s to the early 1970s. The daughters of women who took DES have an increased risk of developing a rare type of adenocarcinoma.

Signs and symptoms

You might not experience any obvious symptoms. Early changes in the cells of the cervix rarely cause symptoms, which is why you are encouraged to have regular Pap smears.

If early cell changes develop into cervical cancer, you may notice:

  • vaginal bleeding between periods, after intercourse or after menopause
  • pelvic pain or pain during intercourse
  • vaginal discharge with unusual consistency or odour
  • excessive tiredness
  • leg pain or swelling
  • lower back pain

You may have nothing to worry about if you experience these symptoms, as they can all be caused by many other conditions. However, if you notice one or more of these symptoms you should bring it to the attention of your doctor for further investigation. If you experience signs and symptoms of cervical cancer or if a Pap smear test has revealed abnormal cells, you will need to undergo further tests.

A Pap smear (also referred to as a Pap test) is a test that picks up any changes to the cells in your cervix. The aim of a Pap smear is to find and treat abnormal cells before cervical cancer develops.

The NSW Cervical Screening Program recommends that you should have a Pap smear once every two years if you are aged between 18 and 70 years and have ever been sexually active. In NSW, about 5% of Pap smear results show abnormalities, meaning that the cells taken during the Pap smear look different to the ‘normal’ cells in your cervix.

These abnormalities do not mean you have cancer, but your GP will probably want to do some further tests to get a better understanding of what has caused the test result. Abnormal looking cells are often caused by infection or irritation, so repeating the Pap smear after a period of time (e.g. 12 months) will usually show that the cells have returned to normal. If the follow-up Pap smear indicates that the abnormality is still there, you will probably be sent for further tests.

There are several types of early cellular changes that a Pap smear can identify, including:

Atypia: slight changes in the cells of the cervix. Many factors can make normal cells appear atypical, including infection or irritation.

Dysplasia: precancerous changes in the cells of the cervix. Also called cervical intraepithelial neoplasia (CIN), of which there are two types:

  • CIN1 or low-grade dysplasia – early changes that usually disappear without treatment.
  • CIN2, CIN3 or high-grade dysplasia – cells continue to change and treatment will be needed.

For more information about having a Pap smear, including what the test involves and where you can have the test done, please visit the following website:
http://www.csp.nsw.gov.au/having-your-pap-test/what-does-a-pap-test-involve

Diagnosis

General tests

If you have an abnormal Pap smear result, you will most likely be sent for a colposcopy, which will help to identify where the abnormal cells are. Sometimes a small biopsy (sample of tissue) may be taken or a larger sample (Loop Electrosurgical Excision Procedure (LEEP) of the transformation zone) but in other cases your doctor may perform a wider biopsy (called a cone or incision biopsy).

More information about each of the diagnostic procedures is provided below:

Colposcopy

A colposcopy is an examination that allows the doctor to see a magnified view of the cervix, vagina and vulva. It is done using an instrument called a colposcope, which is like binoculars on a stand. The colposcope doesn’t enter the body – the doctor inserts an instrument called a speculum and views the magnified picture through the colposcope. Beforehand, the vagina and cervix may be coated with a special solution to highlight abnormalities.

A colposcopy takes about 10-15 minutes and can be slightly uncomfortable.

Biopsy

A biopsy is a small sample of tissue, which may be taken from an abnormal area on the cervix and sent to a laboratory for examination. A colposcope will be used to see what area needs to be removed.

The procedure may be uncomfortable for a brief period. It is usually done in the doctor’s rooms or in a clinic and the results are usually back within about a week.

Loop Electrosurgical Excision Procedure (LEEP)

A LEEP (also called a LLETZ or LOOP) uses a wire heated by an electrosurgical generator to cut through cervical tissue like a scalpel. During the procedure, a large tissue sample will be removed for examination under a microscope.

A LEEP takes about 10 minutes and is sometimes done at the same time as a colposcopy. It is usually performed under local anaesthetic in the clinic but is occasionally performed under general anaesthetic in the operating room (particularly when the colposcopy was not well tolerated or if the abnormality on the cervix is large).

You will probably not experience any pain, but occasionally there is mild “period-like” cramping. The procedure may also cause a discharge that is dark brown to black or, in some instances, bloody.

Cone biopsy

A cone (or incision) biopsy may be conducted to see if the abnormal cells have spread to tissue beneath the surface of the cervix. A cone-shaped piece of tissue containing abnormal cells is removed.

A cone biopsy is done under general anaesthetic and may involve day or overnight admission to hospital. The results are usually back within about a week.

Further tests

Additional tests may be conducted to check general health and see whether the cancer has spread. The following scans are often required to determine the stage of cervical cancer:

Computed tomography (CT) scan

A CT scan (also called a CAT scan) uses X-ray beams to create a detailed, three-dimensional image the body. The CT scanner is a large, circular machine. You will lie on a table while the scanner rotates for approximately 30 to 40 minutes.

To make the image clearer, you may be asked to drink a special liquid that contains a dye, have a tampon inserted into your vagina, or have a dye inserted in your rectum. The dye may cause you to experience a hot feeling all over for a few minutes.

Magnetic Resonance Imaging (MRI) scan

An MRI scan (also called nuclear magnetic resonance imaging or NMRI) uses radio waves and a powerful magnet to create a cross-sectional image of the body. The image can show the difference between healthy tissue and diseased tissue and makes better images of organs and soft tissue than other scanning techniques, such as CT scans or X-rays.

The MRI scanner is like a big metal tube. You will lie on a table that moves in and out of the tube for approximately one hour. You may be injected with a dye before the scan to make the image clearer.

Positron Emission Tomography (PET) scan

A PET scan uses the emissions from a mild, radioactive glucose solution to create images that explain how certain organs or systems in the body are functioning.

The glucose is given as a simple and painless injection and may take up to 50 minutes to circulate through your body. You will lie on an imaging bed which has arm, leg and head rests to help you keep still. The imaging bed then passes through a large circular scanner, which takes up to one hour.

Determining the stage and grade of your cervical cancer can help your health care team work out what treatment is best and what your prognosis (or expected outcome) is.

Your cancer will be assigned a stage (I-IV) which describes whether it has spread beyond your cervix and to other organs or parts of the body.

  • Stage I – the cancer cells are present only within the cervix.
  • Stage II – the cancer has spread into surrounding structures such as the upper part of the vagina or tissues next to the cervix.
  • Stage III – the cancer has spread more widely to surrounding structures such as the lower part of the vagina or to the sides of the pelvis.
  • Stage IV – the cancer has spread to the bladder or bowel or beyond the pelvic area. This stage includes cancer that has spread into the lungs, liver or bone, although these are not common.

The grade describes how fast the cancer cells are growing and how aggressive your cancer is likely to be.

  • Grade 1 – the cancer cells look very similar to the normal cells of the cervix. They usually grow slowly and are less likely to spread.
  • Grade 2 – the cancer cells look more abnormal and are more likely to spread.
  • Grade 3 – the cells look very abnormal or “angry”, and are likely to grow quickly and spread.

Which health professionals will I see?

You will be cared for by a range of health professionals who specialise in different aspects of your treatment. Health professionals who may care for you include:

General practitioner (GP) – arranges the first tests to assess your symptoms. A GP can also explain information provided by specialists and other health professionals to help with treatment decisions and direct women with cervical cancer to sources of practical and emotional support.

  • Gynaecological oncologist – is a specialist surgeon who treats women with cancers of the reproductive system.
  • Medical oncologist – is a specialist doctor who prescribes and coordinates the course of chemotherapy.
  • Radiation oncologist – is a specialist doctor who prescribes and coordinates the course of radiotherapy.
  • Radiologist – a specialist trained to read and interpret diagnostic scans (e.g. CT, MRI and PET scans).
  • Oncology nurses – are trained in cancer care and help administer drugs, including chemotherapy, and provide care, information and support throughout treatment.
  • Cancer nurse coordinator or cancer care coordinato r – provides support to patients and families throughout treatment and liaises with other staff.
  • Genetic counsellor – is a health professional that provides advice for women with a strong family history of cancer.
  • Dietitian – is a health professional that recommends an eating plan to follow during treatment and recovery.
  • Psychologist – is a health professional that helps to address the emotional and other impacts of cancer.
  • Social worker, physiotherapist, and occupational therapist – are health professionals that help to link women with support services and help with any emotional, physical or practical problems.

Treatment

When cervical cancer is detected in its earliest stages, treatment is more likely to be successful. Your health care team will recommend the most effective treatment(s) based on the results of all of your tests and investigations. You may also have personal preferences about your treatment based on factors such as your age and other health problems. Together you and your health care team will decide on the best treatment options for you.

Surgery

If you are diagnosed with cervical cancer in the early stage, you will probably undergo surgery. The advantages of surgery are:

  • You will experience fewer long term side effects; and
  • Radiotherapy can be used after surgery at a later date if you require further treatment.

In some circumstances it is more appropriate to use radiotherapy with or without chemotherapy as the first treatment. The extent of the cancer in your cervix will determine which of the following types of surgery you will need:

Cone biopsy/LEEP

If the tumour on your cervix is very small, you may only require a cone biopsy. A cone biopsy is done under general anaesthetic and will involve the removal of a cone-shaped piece of your cervical tissue.

Hysterectomy

If your tumor is larger or more advanced you may require a hysterectomy. A total hysterectomy is an operation in which the uterus and cervix are removed. A hysterectomy can cure early-stage cervical cancers and prevent the cancer from coming back, but removing the uterus makes it impossible to become pregnant.

A radical hysterectomy involves the removal of the uterus and cervix, as well as a margin of healthy tissue around the tumour, including about two centimeters of the upper vagina. It may affect your bowel and bladder function and may lead to incontinence.

If your ovaries and fallopian tubes are also affected by your cancer, you may also require their surgical removal. This procedure is called an oophorectomy.

Trachelectomy

If you are a young women who does not wish to undergo a hysterectomy and lose your fertility you may have the option to undergo a trachelectomy. A trachelectomy is the surgical removal of the cervix. If you undergo this procedure you will continue to have regular menstrual periods after treatment.

There are risks associated with this procedure, and such an approach would only be offered after extensive discussion with you.

Lymphadenectomy

Unless you are diagnosed with cervical cancer at a very early stage, you will require a pelvic lymphadenectomy (removal of lymph nodes). A lymphadenectomy is carried out to assess whether the cancer has spread to the lymph nodes. The removal of lymph nodes may cause leg swelling (lymphoedema) particularly if surgery occurs in combination with radiotherapy. If the lymph nodes appear to be affected, chemotherapy and radiotherapy may be given without surgery, even for early cancers.

If there is evidence that your cancer has spread into other organs or parts of your body, your surgery will probably be followed with radiotherapy, with or without low dose chemotherapy, to decrease the chance of the cancer returning.

Radiotherapy

Radiotherapy is often used after surgery if your cancer has spread to the lymph nodes or the surrounding normal tissue. The treatment involves high energy rays (similar to X-rays) which target cancer cells and damage or destroy them. The rays come from an external machine, and you will therefore be required to attend hospital five days a week for up to six to eight weeks. Each radiotherapy treatment takes just a few minutes, and it is painless.

In addition to external radiotherapy, you may receive internal radiotherapy, known asbrachytherapy . Brachytherapy involves placing a radioactive material internally, on or near the cancer. Brachytherapy for the treatment of cervical cancer involves the insertion of small cylindrical, radioactive implants into your vagina and cervix. The implants stay in position for between two and 72 hours depending on the dose you require.

Generally, doctors try to limit the amount of radiation that you receive to your vital organs, and avoid treating large portions of your bowel and pelvis to reduce damage to your healthy tissues. Importantly, radiotherapy may cause premenopausal women to stop menstruating and begin menopause.

Chemotherapy

Chemotherapy uses drugs called cytotoxins to kill or slow the growth of cancer cells. Its role is to make the radiation work more effectively, and to kill any cancer cells that may have spread outside of your pelvic region.  Chemotherapy drugs are usually injected into a vein. They travel throughout your body killing rapidly growing cells, including cancer cells. Certain chemotherapy drugs may cause early menopause and infertility in premenopausal women.

It is very common for women with cervical cancer to have chemotherapy and radiotherapy at the same time (known as chemoradiation ). In most instances, low dose chemotherapy will be given once a week for the duration of radiotherapy. The side effects of chemoradiation are greater than for either chemotherapy or radiotherapy alone, but it has been shown to be an effective way of treating cervical cancer.

If you are diagnosed with advanced cancer or if your cancer returns, higher doses of chemotherapy may be offered by itself to help control symptoms.

Long-term side effects of treatment

Sometimes the treatment that successfully gets rid of your cancer may have long-term side effects. These might include:

Menopause

If you have undergone certain treatments including chemotherapy, radiotherapy to the pelvis, or have had both ovaries removed you may experience “instant” or “early” menopause. Menopause is usually a gradual transition that takes place over months or years. Instant menopause is a big adjustment, psychologically as well as physically.

Infertility

Surgery, chemotherapy and radiotherapy can affect your ability to have children naturally after cervical cancer. Therefore, you and your health care team must carefully discuss and consider treatment options that will have any long term effects on your fertility. If this is important, you can also speak to a fertility specialist.

Lymphoedema

Lymphoedema is chronic swelling of a limb (usually the legs in women with cervical cancer). It happens because the cancer or its treatment has affected the normal fluid drainage channels known as the lymphatic system. Fluid called lymph begins to collect in one area and does not drain in the normal way.

Lymphoedema as a result of cancer or its treatment cannot be completely cured. However, there are many ways of treating your symptoms such as swelling and pain.

Palliative treatment

Palliative treatment helps improves people’s quality of life by alleviating symptoms of cancer. It is particularly important for people with advanced cancer.

Treatment may be concerned with pain relief and management of physical and emotional problems.

Vaccinating against HPV is the best way to prevent cervical cancer. Eligible males and females aged 12-13 years can take part in the school-based National Human Papillomavirus (HPV) Vaccination Program. In 2014, males aged 14-15 years are also able to receive the vaccine through a catch-up program.

For more information, please refer to the following website:

Human papillomavirus (HPV) immunisation service

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