There are new developments in cervical cancer screening programs
Cervical cancer is the second most common cancer in women worldwide. In our country it is placed 9th among cancers in women, and every year approximately 1500 women are diagnosed with cervical cancer (cancer of the uterine cervix). Associate Professor Korhan Kahraman, Obstetrics and Gynecology Specialist from Atakent Acibadem Hospital, tells us all the details, from routes of transmission to symptoms, from diagnosis and management to changes in screening methods, that need to be known about cervical cancer.
1- What are the causes of cervical cancer, and which women are under greater risk?
The cervical infection caused by Human Papilloma Virus (HPV) is the most significant cause of cervical cancer. Because HPV is a sexually transmitted virus, it is directly related to the sexual lifestyle. The risk of HPV infection and the related disorders are increased in individuals who have had sexual intercourse at an early age (before age 21), who have multiple partners or intercourse with high risk carrier males (multiple partners). Some of the other risk factors reported for cervical cancer are multiple births (more than 3), smoking, other infections of the cervix, a deficiency in the immune system against microorganisms, a low socioeconomic status, use of oral contraceptives from an early age and for a long period of time.
2- How is the mechanism that HPV is causes cervical cancer?
Not all types of HPV that cause cervical infections induce cancer. Approximately 15 types of HPV are known to be related with cancer. Especially HPV 16 and 18 are the types that evolve to cancer most frequently. Any type of contact with skin and body fluids that harbor HPV may result in onset of infection. It is spread to 2/3 of those who are involved in a sexual intercourse with the infected individual. However, not all HPV infection types should cause extreme anxiety. This is because the infection resolves by itself in 70 percent of the individuals within the year that follows the infection, and in 90 percent within the two years. In other words, if the individual’s immune system is functioning normally the body can destroy this virus. Only 10 percent of the women who have an HPV infection develop a chronic infection. High risk HPV, in other words having a carcinogen effect, transmits its own genetic structure to the cells that it invades, eventually resulting in the onset of a series of interactions. The period between transmission of HPV and onset of cancer occurs within a period of 10-15 years, and manifests itself as a series of “cancer precursor” lesions. The main goal of cervical cancer screening programs is to detect these cancer precursor lesions, and prevent the development of cancer.
3- Is it possible to be protected from cervical cancer?
The most important method in protection is a screening test that relies on examining cells in the smear samples obtained by a small tool from the cervix (Pap-smear test). It is known that in the countries where this test is applied, there is a 70 percent reduction in the occurence of cervical cancer and related deaths. Despite this fact, this cancer continues to threaten women’s health in especially underdeveloped or in some of the developing countries. Another method of protection is HPV vaccines applied also in our country.
HPV test is recommended in addition to smear test
All women should join cervical cancer screening programs after age 21. Although there are various screening programs today, guiding foundations such as American College of Obstetricians and Gynecologists and American Cancer Society recently published reports that included their current recommendations. According to these guides; “Women between 21-29 years of age should be scanned with a smear test every 3 years, women aged 30 or above should be scanned every 5 years with the double test that includes smear test and HPV test.” On the other hand, it is stated that when the HPV test cannot be performed, scanning with only a smear every 3 years is also an acceptable approach. These screening intervals reported above can differ when there is a pathologic smear result (abnormal smear). Screening is recommended to continue until age 65-70. There is not yet an official change in the cervical cancer screening program in our country, annual screening with smear continues. We tell all women not to neglect their annual gynecologic examinations and toundergo regular smear tests.
4- What is the latest situation in the vaccines developed against cervical cancer?
There are two different types of protective HPV vaccines. The first is the quadrivalent vaccine developed against types HPV 6, HPV 11, HPV 16, and HPV 18. The HPV types covered by the quadrivalent vaccine is used against HPV 16 and HPV 18 which are held responsible against 70% of the cervical cancers, as well as HPV and HPV 11 which are responsible from genital warts and unrelated to cancer. The other vaccine is the bivalent vaccine used for HPV 16 and HPV 18.
Studies that have been performed showed that both vaccines had 90 percent success in preventing the cancer precursor lesions or the cancer itself that are related to the virus types included in the vaccine. This rate reaches the peak in women who are sexually inactive, in other words who have never contacted HPV. In order to gain the most successful effect, it is useful to be vaccinated during childhood. The suggested age for childhood is 11-12. This may be also done at ages 9-10 when desired. Those who were not vaccinated in childhood must be vaccinated until age 26. Although there are different opinions, this age limit may be increased up to 45 if neglected.
5- When should women suspect cervical cancer?
Most cervical cancers do not cause any symptoms during the early phase, when they do the most common complaint is vaginal bleeding. This bleeding may be in the form of spotting that is seen outside the menstrual periods of women, or more typically it may be bloody staining that is noticed during or immediately after intercourse. It should be remembered also that although the emergence of bleeding in women after menopause is more often related to cancers arising from the inner lining of the uterus, cervical cancer may also be a cause. When the cancer invades the neighboring structures in advanced stage, the patients may experience difficulties in the passage of urine or stool, leg pain, or accumulation of fluids in the legs.
6- How are cervical cancers treated?
There are 2 main methods in the treatment. The first is surgical treatment. Although it may show some variations, the standart surgical method in the early stage includes removal of the uterus together with neighboring tissues possibly affected by spread of the cancer and the lymph nodes. Following the operation beam treatment (radiotherapy), either alone or together with chemotherapy may need to be applied in some of these patients. The other treatment method is treatment of the patient with radiotherapy and concomitant chemoterapy, and without surgery. The treatment option where radiotherapy is given as the major method is applied to patients with advanced disease who cannot undergo surgery.
7- Can mothers treated for cancer of the cervix give birth?
A significant difference of cervical cancers from other gynecologic cancers is the occurrence of this cancer more commonly in women in reproductive age. Therefore the selection of treatment carries a special significance for patients in this age group who also wish to have children. In patients in this age group it is possible only to remove the cervix and the lymph nodes and preserve the main body of the uterus, thereby making childbirth possible. However, in order to make such an opeation a meticulous evaluation before the operation is needed to determine whether the patient fulfills the criteria. Thanks to the operations in this appropriate age group, many women can both be relieved from the illness and also have children.
8- Which method should be chosen in the treatment of cervical cancers?
Today, almost all gynecologic procedures in the abdomen can be performed by laparoscopic methods. A significant advantage of laparoscopy over open surgery is that it saves the patient from big incisions on the abdomen, making it possible to do the operation with millimetric sized (5-12 mm) small holes, a camera inserted inside the abdomen, and very small size surgical tools. Also because all organs and structures can be seen with greater detail compared to open surgery, the operation can be performed with the desired meticulousness. Patients operated with laparoscopy have less pain, shorter stay in the hospital, and more rapid return to normal life. In addition, the robot technology that has begun to be used recently allows the surgeons to operate under a 3 dimensional view and to use their hands almost at the comfort of open surgery. Robotic surgery enables some complicated aspects of surgery such as cervical cancer to be treated more easily and with greater meticulousness.