Cervical cancer is a malignant cancer of the cervix. It may present with vaginal bleeding but symptoms may be absent until the cancer is in its advanced stages, which has made cervical cancer the focus of intense screening efforts using the Pap smear.

 In developed countries, the widespread use of cervical screening programs has reduced the incidence of invasive cervical cancer, by 50% or more. Most scientific studies have found that human papillomavirus (HPV) infection is responsible for virtually all cases of cervical cancer Treatment consists of surgery (including local excision) in early stages and chemotherapy and radiotherapy in advanced stages of the disease. An effective HPV vaccine against the two most common cancer-causing strains of HPV has recently been licensed in the U.S. These two HPV strains together are responsible for approximately 70% of all cervical cancers. Experts recommend that women combine the benefits of both programs by seeking regular Pap smear screening, even after vaccination.

Classification 

Cervical cancer is a carcinoma, typically composed of squamous cells, and is similar in some respects to squamous cell cancers of the head and neck and anus. All three of these diseases may be associated with human papillomavirus infection.

 Signs and symptoms

 The early stages of cervical cancer may be completely asymptomatic (Canavan & Doshi, 2000). Vaginal bleeding, contact bleeding or (rarely) a vaginal mass may indicate the presence of malignancy. Also, moderate pain during sexual intercourse and vaginal discharge are symptoms of cervical cancer. In advanced disease, metastases may be present in the abdomen, lungs or elsewhere.

 Symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, single swollen leg, heavy bleeding from the vagina, leaking of urine or feces from the vagina, and bone fractures. 

Causes

 The American Cancer Society provides the following list of risk factors for cervical cancer: human papillomavirus (HPV) infection, smoking, HIV infection, chlamydia infection, dietary factors, hormonal contraception, multiple pregnancies, use of the hormonal drug diethylstilbestrol (DES) and a family history of cervical cancer.

 Human papillomavirus infection

 The most important risk factor in the development of cervical cancer is infection with a high-risk strain of human papillomavirus. Even though HPV is an important risk factor for cervical cancer, most women with this infection do not get cervical cancer and doctors believe other risk factors must come into play for this cancer to develop. Having unprotected sex, especially at a young age, makes HPV infection more likely. Women who have many sexual partners (or who have sex with men who have had many partners) have a greater chance of getting HPV.

 

Diagnosis

 Biopsy procedures

 While the pap smear is an effective screening test, confirmation of the diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using an acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix.

 Further diagnostic procedures are loop electrical excision procedure (LEEP) and conisation, in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe cervical intraepithelial neoplasia.

 Pathologic types

 Cervical intraepithelial neoplasia, the precursor to cervical cancer, is often diagnosed on examiniation of cervical biopsies by a pathologist. Histologic subtypes of invasive cervical carcinoma include the following: 

    * squamous cell carcinoma (about 80-85%)

    * adenocarcinoma

    * adenosquamous carcinoma

    * small cell carcinoma

    * neuroendocrine carcinoma

 Non-carcinoma malignancies which can rarely occur in the cervix include

     * melanoma

    * lymphoma

 

 Treatment

 Microinvasive cancer (stage IA) is usually treated by hysterectomy (removal of the whole uterus including part of the vagina). For stage IA2, the lymph nodes are removed as well. An alternative for patients who desire to remain fertile is a local surgical procedure such as a loop electrical excision procedure (LEEP) or cone biopsy.

 If a cone biopsy does not produce clear margins, one more possible treatment option for patients who want to preserve their fertility is a trachelectomy. This attempts to surgically remove the cancer while preserving the ovaries and uterus, providing for a more conservative operation than a hysterectomy. It is a viable option for those in stage I cervical cancer which has not spread; however, it is not yet considered a standard of care, as few doctors are skilled in this procedure. Even the most experienced surgeon cannot promise that a trachelectomy can be performed until after surgical microscopic examination, as the extent of the spread of cancer is unknown. If the surgeon is not able to microscopically confirm clear margins of cervical tissue once the patient is under general anesthesia in the operating room, a hysterectomy may still be needed. This can only be done during the same operation if the patient has given prior consent. Due to the possible risk of cancer spread to the lymph nodes in stage 1b cancers and some stage 1a cancers, the surgeon may also need to remove some lymph nodes from around the womb for pathologic evaluation.

 A radical trachelectomy can be performed abdominally or vaginally and there are conflicting opinions as to which is better. A radical abdominal trachelectomy with lymphadenecectomy usually only requires a 2- to 3-day hospital stay, and most women recover very quickly (approximately 6 weeks). Complications are uncommon, although women who are able to conceive after surgery are prone to preterm labor and possible late miscarriage. It is generally recommended to wait at least one year before attempting to become pregnant after surgery. Recurrence in the residual cervix is very rare if the cancer has been cleared with the trachelectomy. Yet, it is recommended for patients to practice vigilant prevention and follow up care including pap screenings/colposcopy, with biopies of the remaining lower uterine segment as needed (every 3-4 months for at least 5 years) to monitor for any recurrence in addition to minimizing any new exposures to HPV through safe sex practices until one is actively trying to conceive.

 Early stages (IB1 and IIA less than 4 cm) can be treated with radical hysterectomy with removal of the lymph nodes or radiation therapy. Radiation therapy is given as external beam radiotherapy to the pelvis and brachytherapy (internal radiation). Patients treated with surgery who have high risk features found on pathologic examination, are given radiation therapy with or without chemotherapy in order to reduce the risk of relapse.

Prevention

Awareness

According to the US National Cancer Institute's 2005 Health Information National Trends survey, only 40% of American women surveyed had heard of human papillomavirus (HPV) infection and only 20% had heard of its link to cervical cancer. In 2006 an estimated 10,000 women in the US will be diagnosed with this type of cancer and nearly 4,000 will die from it.

 

Screening

The widespread introduction of the Papanicolaou test, or pap smear for cervical cancer screening has been credited with dramatically reducing the incidence and mortality of cervical cancer in developed countries. The pap smear suggests the presence of cervical intraepithelial neoplasia (premalignant changes in the cervix) before a cancer has developed, allowing for further workup. Recommendations for how often a Pap smear should be done vary from once a year to once every five years. The American Cancer Society recommends that cervical cancer screening should begin approximately three years after the onset of vaginal intercourse and/or no later than twenty-one years of age. If premalignant disease or cervical cancer is detected early, it can be treated relatively noninvasively, and without impairing fertility.

 The HPV test is a newer technique for cervical cancer screening which detects the presence of human papillomavirus infection in the cervix. It is more sensitive than the pap smear (less likely to produce false negative results), but less specific (more likely to produce false positive results) and its role in routine screening is still evolving. Some researchers recommend that since more than 99% of invasive cervical cancers worldwide contain HPV, HPV testing should be done together with routine cervical screening (Walboomers et al, 1999). But, given the prevalence of HPV (around 80% infection history among the sexually active population) others suggest that routine HPV testing would cause undue alarm to carriers.

 

Vaccination 

Merck & Co. has developed a vaccine against four strains of HPV (6,11,16,18), called Gardasil™. It is now on the market after receiving approval from the US Food and Drug Administration on June 8, 2006. Gardasil is targeted at girls and women of age 9 to 26 because the vaccine only works if given before infection occurs; therefore, public health workers are targeting girls before they begin having sex. The use of the vaccine in men to prevent genital warts and interrupt transmission to women is initially considered only a secondary market. The high cost of this vaccine has been a cause for concern. Gardasil has also been approved in the EU. 

GlaxoSmithKline has developed a vaccine called Cervarix™ which has been shown to be 100% effective in preventing HPV strains 16 and 18 and is 100% effective for more than four years. These strains together cause about 70% of cervical cancer cases. Cervarix should be approved by year's end. 

Neither Merck & Co. nor GlaxoSmithKline invented the vaccine. The vaccine's key developmental steps are claimed by the National Cancer Institute in the US, the University of Rochester in New York, Georgetown University in Washington, DC, and the Queensland University in Brisbane, Australia. Both Merck & Co. and GlaxoSmithKline have licensed patents from all of these parties.

 

 Prognosis 

Prognosis depends on the stage of the cancer. With treatment, 80 to 90% of women with stage I cancer and 50 to 65% of those with stage II cancer are alive 5 years after diagnosis. Only 25 to 35% of women with stage III cancer and 15% or fewer of those with stage IV cancer are alive after 5 years.

 According to the International Federation of Gynecology and Obstetrics, survival improves when radiotherapy is combined with cisplatin-based chemotherapy.

 As the cancer metastasizes to other parts of the body, prognosis drops dramatically because treatment of local lesions is generally more effective than whole body treatments such as chemotherapy.

 Interval evaluation of the patient after therapy is imperative. Recurrent cervical cancer detected at its earliest stages might be successfully treated with surgery, radiation, chemotherapy, or a combination of the three. Thirty-five percent of patients with invasive cervical cancer have persistent or recurrent disease after treatment.

 Average years of potential life lost from cervical cancer are 25.3 (SEER Cancer Statistics Review 1975-2000, National Cancer Institute (NCI)). Approximately 4,600 women were projected to die in 2001 in the US of cervical cancer (DSTD), and the annual incidence was 13,000 in 2002 in the US, as calculated by SEER. Thus the ratio of deaths to incidence is approximatley 35.4%.

 Regular screening has meant that pre cancerous changes and early stage cervical cancers have been detected and treated early. Figures suggest that cervical screening is saving 5,000 lives each year in the UK by preventing cervical cancer.

 

Epidemiology

 Worldwide, cervical cancer is the fifth most deadly cancer in women. It affects about 1 per 123 women per year and kills about 9 per 100,000 per year.

 In the United States, it is only the 8th most common cancer of women. In 1998, about 12,800 women were diagnosed in the US and about 4,800 died (Canavan & Doshi, 2000). Among gynecological cancers it ranks behind endometrial cancer and ovarian cancer. The incidence and mortality in the US are about half those for the rest of the world, which is due in part to the success of screening with the Pap smear.

 In Great Britain, the incidence is 8.8/100,000 per year (2001), similar to the rest of Northern Europe, and mortality is 2.8/100,000 per year (2003) (Cancer Research UK Cervical cancer statistics for the UK). With a 42% reduction from 1988-1997 the NHS implemented screening programme has been highly successful, screening the highest risk age group (25-49 years) every 3 years, and those ages 50-64 every 5 years.

 A study published in 2002 (Castellsagué et al) reports that male circumcision can reduce the risk of penile HPV infection in a man, and so the risk of cervical cancer in his female partner. The authors state that "it would not make sense to promote circumcision as a way to control cervical cancer in the US, where Pap smears usually detect it at a treatable stage". However, Menczer (2004) quotes research that male circumcision probably does not contribute to a lower incidence of cervical cancer in Jewish populations.

 One study suggests that prostaglandin in semen may fuel the growth of cervical and uterine tumours and that affected women may benefit from the use of condoms.

 

 

 

 

 

 

 

 

 

 

 

 

Associate Links -  

Computer Animation | 3D Renderings | Health Care | Hair Transplant | Graphic Design | 3D Interior Design | 3D Furniture Design | Ford Quotes | Jewelry Design | Cancer Support | Attorney | Fashion Design | Real Estate | Business Card | Design | Personal Loan | Plastic Surgery | Charity for Children | Mihan | Business Attorney | 3D Animation | Free 3D Models | Graphic Design School | Interior Design | Construction Today |  what is online | Finance India | Design Jewelry | Reiki | Yoga | Nagpur Mihan Chartered Accountant | Nagpur Mihan | Health Forums  | Jewelry Store Catalog | DUI Lawyers |  Latest Jewelry Design |  Ayurveda |  Chikhaldara |   Online Yoga |   Wikipedia |