From a global perspective, cervical cancer is the second most common malignant tumour among women. About 530,000 women contract this form of cancer every year. In Austria, thanks to a targeted, efficient examination (a Pap test at the gynaecologists), the majority of cell changes on the cervix are identified as benign precursors that can be removed with a minor surgical procedure.
This cancer is often diagnosed between the ages of 40 and 50, reaching a second peak at between 65 and 75 years. Benign precursors of cervical cancer can occur even in young women between the age of 20 and 30. While the number of malignant cervical tumours has been reduced through the availability of preventive medical examinations, its precursors are found ever more frequently.
Nearly all diagnosed cervical cancers are caused by infection with certain types of the human papilloma virus (HPV), the disease developing very gradually – often over several years – with no symptoms by which it could be identified. When symptoms occur, the cancer is likely to already have reached an advanced stage.
Infection with the human papilloma virus generally takes place in adolescence, with the first sexual contacts. Besides using a condom, the HPV vaccination is the only available effective protection. Gynaecologists advise especially young girls, but also boys, to have the HPV vaccination before their first sexual intercourse. If cell changes caused by an HPV infection have already taken place on the cervix, the vaccine has no effect; in that case, other medical steps must be taken.
Because cervical cancer usually exhibits no symptoms in its early stages, an annual check-up with a Pap test at the gynaecologist is absolutely necessary for women from the age of 20. Through this test, even precursors of cervical cancer can be detected and successfully treated.
For the Pap test (also called smear test), the doctor takes small samples from the cervix and from the cervical canal with a small brush or spatula.
These are then examined in the laboratory. It must be noted, however, that the false negative rate (i.e. the proportion of tests at which a disease is already present but is not detected by the test) is up to 50 percent. This means that a single negative sample does not guarantee that the patient does not have the disease. It is therefore particularly important to have regular check-ups: while this cannot prevent the condition from developing, it can at least help identify it early on. In addition to the Pap test, women can also take an HPV test. This aims to determine whether they are infected with the cancer-causing HPV virus and – together with the findings from the Pap test – allows the risk of cervical cancer to be better assessed. If the result is negative, the patient is highly unlikely to have a precursor to cervical cancer or the cancer itself caused by the HP virus.
Regardless of this diagnosis, a doctor should be consulted if vaginal discharge, bleeding between periods or pain in the abdomen occurs. Even if these symptoms are more likely to be caused by an inflammation or hormonal disorders in most cases, they should be dealt with just to make sure.
Oncology has the almost unique ability of not only detecting cervical cancer early on but to actually prevent its occurrence. It is now known that cervical cancer is caused by a virus – the human papilloma virus or HPV. HPV vaccination can today prevent almost 100 percent of all occurrences of cervical cancer.
The vaccination should be carried out before the first sexual contact. Two years later, four out of ten young women are already infected with the virus. Immunisation is achieved with three injections over the course of no more than a year. The vaccine prevents infection with the most important cancer-causing types of human papilloma virus (types 16 and 18) and can therefore prevent the development of cervical cancer, which is caused by these types of the virus.
It protects anyone who has not yet had any sexual contact with an infected partner and can also be useful for women after their first sexual contact. People who have been infected with these virus types can prevent re-infection through a vaccination. Once cells have been affected, however, the vaccine can no longer provide protection. Even vaccinated women should have regular check-ups, since the HPV vaccine, while being very effective, cannot guarantee that cervical cancer will not occur and does not protect against all types of HPV.
As already mentioned, the HP virus is usually transmitted through sexual contact. Although condoms can reduce the risk of infection, they do not provide foolproof prevention, since papilloma viruses can reside in areas that are not covered by the condom.
The Pap test should be done once a year during a routine check-up at the gynaecologist. From its result, any asymptomatic precursors to cancer – cervical intraepithelial neoplasia (CIN) – can often be identified early on and therefore effectively treated. When slight changes are found, further action besides the usual routine check-ups is not usually required, since these generally disappear again by themselves. In the event of moderate changes, a check-up every few months is recommended. If the changes have not regressed within a year, an examination of the cervix using magnifying optics (colposcopy) and tissue samples are indicated.
The samples are examined histologically to obtain a diagnosis. Samples from an area of the affected cervix can be taken either with a biopsy or by scraping off a small amount of the mucous membrane of the cervix (curettage). If the Pap tests repeatedly yield suspicious results and if more pronounced changes in the area of the cervix are evident, a conisation is also carried out. This is a type of biopsy in which the gynaecologist cuts out a cone-shaped piece of tissue that fully covers the area with cell changes from the mouth and neck of the uterus. A conisation is performed under anaesthesia. If cervical cancer is identified, the spread (staging) of the disease must be determined with a gynaecological examination.
If significant changes are identified, a colposcopy and biopsy are carried out immediately.
To determine the extent to which the cancer has spread, further tests are necessary before operating.
In addition to performing a Pap test, women can also take an HPV test, as described above. A negative HPV test largely rules out the presence of a precursor to cervical cancer and the cancer itself.
The determination of so-called tumour markers may be useful in some cases, but is not part of the routine programme.
In recent decades the introduction of the Pap test has resulted in a sharp decline in cervical cancer. Through regular check-ups, nearly all cases can be detected at their preliminary stage. Because cervical cancer often causes symptoms – such as pain or flesh-coloured discharge – only at an advanced stage, early diagnosis is possible only by gynaecologists. Once symptoms occur, valuable treatment time is already lost.
At the early stage (micro-invasive cervical cancer), a conisation – a cone-shaped biopsy of the cervix and the lining of the cervical canal – is sufficient, especially if the patient still wants to have children. If larger tumours that have not spread beyond the uterus are found, the entire uterus (hysterectomy) complete with its supportive tissue and the lymph nodes along the large pelvic vessels are usually removed by an abdominal section. As with the ovarian cancer, the removal of adjacent organs and surrounding tissue may be necessary if the cancer has spread beyond the uterus. Because this is a major operation that results in severe side-effects, a less radical method is chosen wherever possible.
If the patient is pregnant, the choice of procedure depends on the stage of both tumour and pregnancy. Micro-invasive cancers can be fully removed through a cone biopsy, allowing the pregnancy to continue and the child to be born naturally. With later-stage tumours and an early stage of pregnancy, appropriate surgical treatment should be carried out, which means terminating the pregnancy. If the patient is at a later stage of pregnancy, the birth should be initiated as soon as possible by caesarean section and a hysterectomy with lymph node removal performed.
In advanced cancer stages, a combined radiotherapy and chemotherapy is necessary. This treatment is carried out in close cooperation with radiotherapists. After surgery, radiotherapy combined with chemotherapy is indicated only for patients who are at high risk of a recurrence of the disease. Patients whose surgical cuts are infected during the operation or that have infected lymph nodes and parametria should receive a postoperative radiation and chemotherapy.
Women with two of the following three risk factors should also receive radiation and chemotherapy: large tumour volume, deep stroma in the area of the cervix, and an invasion of lymphatic or blood vessels. Two methods of radiotherapy are available: contact radiation and percutaneous high-voltage radiation. If the aim of treatment is to heal the patient, initial treatment consists of a combination of the two methods. In contact radiotherapy, remote-controlled radiation source is briefly inserted into the vagina. This allows a very accurate application of the radiation to destroy tumour tissue without affecting surrounding sensitive organs, such as the bladder and intestines. Percutaneous high-voltage radiation therapy is applied through the skin from the outside. Here, too, computer-aided treatment planning helps minimise exposure of healthy tissue to the radiation. Radiation and chemotherapy are toady usually used in combination, as this improves the results of treatment.
For the first three years after therapy, patients should attend follow-up examinations every three to four months, with further check-ups twice a year in the fourth and fifth year and, unless further complications arise, annual check-ups thereafter.
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