CERVICAL CANCER SCREENING
The Pap smear (Pap test) is a test used to screen women for cervical dysplasia/precancerous cells. HPV testing can also be used to screen women.
WHO SHOULD HAVE A PAP SMEAR?
The first Pap test is recommended at age 21 as cervical cancer is very rare in younger women.
Pap testing is suggested every one to two years for most women age 21 to 29 years old, and every two to three years for most women age 30 or older. Other risk factors for cervical cancer may also affect these recommendations.
Women who are 65 years or older can stop having Pap tests if:
You have had Pap tests on a regular basis in the past and have had at least three normal Pap tests in a row and no abnormal Pap tests in the past 10 years
Women who have had a total hysterectomy (your uterus and cervix were removed) do not need a Pap test, unless:
The hysterectomy did not remove your cervix (eg, if the hysterectomy was "subtotal")
Your hysterectomy was done because of cervical cancer or precancer
You were exposed to diethylstilbestrol (DES) during your mother's pregnancy.
CERVICAL CANCER RISK FACTORS
The most important risk factor for cervical cancer is infection with the human papillomavirus (HPV). There are over 100 different types of HPV, however most types of HPV do not cause cancer. At least 80 percent of women are exposed to the HPV virus during their lifetime. Most of the time, the body's immune system gets rid of the virus before it does harm.
Researchers have labeled the HPV types as being high or low risk for causing cervical cancer.
Low risk types — HPV types 6 and 11 are the most common and can cause genital warts.
High risk types — HPV types 16 and 18 are the most common and are considered high-risk types because they may cause cervical cancer in some women.
HPV is spread by direct skin-to-skin contact usually through sexual contact. There are currently 2 vaccines that have been developed against the most common HPV strands.
Most people who are infected with HPV have no signs or symptoms. Most HPV infections are temporary and resolve within two years. When the virus persists (in 10 to 20 percent of cases), there is a chance of developing cervical precancer or cancer. However, it usually takes many years for HPV infection to cause cervical cancer.
WHAT IF I HAVE AN ABNORMAL Pap SMEAR?
Colposcopy is used to follow up abnormal cervical cancer screening tests or abnormal areas seen on the cervix, vagina, or vulva.
The colposcope magnifies the appearance of the cervix and allows the clinician to better see where the abnormal cells are located and the size of any abnormal areas. Colposcopy is performed like a pelvic examination. The physician will use acetic acid (vinegar) to help identify lesions on the cervix (vagina or vulva) Directed biopsies can then be performed to rule out invasive cancer.
WHAT IS THE TREATMENT OF DYSPLASIA OR PRECANCEROUS CELLS?
Dysplasia of the cervix is graded as cervical intraepithelial neoplasia (CIN) 1 through 3, with CIN3 considered a high grade lesion or carcinoma-in-situ. Treatment depends on the grade and can include
Observation – Commonly done for CIN1 as most of the lesions will regress spontaneously. Repeat Pap smears will be done at 6 and 12 months.
Laser ablation – Typically used in the lower grade lesions.
LEEP or Cold Knife Conization (CKC) – Both of these procedures are excisional biopsies. A LEEP is often performed in the office and a CKC in the operating room. The type of excision is dependent on the patient and the disease. They are both diagnostic in that they can rule out an underlying invasive cancer and therapeutic to cure the dysplastic lesion.
Hysterectomy – This is not an option for newly diagnosed cervical dysplasia, but is an option for patients with microinvasive cancer, other gynecological issues in addition to cervical dysplasia and persistent or recurrent CIN2 or 3.
What are the symptoms of cervical cancer?
Cervical cancer may be asymptomatic at first. The most common symptoms include bleeding:
In between menstrual cycles (other than your during period)
CERVICAL CANCER STAGING
Cervical cancer is staged clinically by physical examination and possibly additional radiological tests such as a chest x-ray, IVP, or barium enema. Staging is based on the tumor size and the extent of regional tissue involvement. CT scans and PET/CT scans are not used for staging, but are commonly used to access the extent of disease and help in deciding the appropriate treatment.
| Stage I ||IA1 ||Microinvasive cancer with depth of invasion < 3mm |
| ||IA2 ||Microinvasive with depth of invasion >3 mm but <5 mm. No larger than 7 mm horizontal spread. |
| ||IB1 ||Tumor ≤ 4 cm |
| ||IB2 ||Tumor > 4 cm |
| Stage II ||IIA1 ||Tumor involves the upper vagina but ≤ 4 cm |
| ||IIA2 ||Tumor involves the upper vagina but > 4 cm |
| ||IIB ||Tumor involves the parametrium (tissue adjacent to the cervix) |
| Stage III ||IIIA ||Tumor spreads to the lower 1/3 of the vagina |
| ||IIIB ||Tumor extends to the pelvic wall and/or causes obstruction of the ureter |
| Stage IV || IVA ||Tumor invades into the bladder or rectum |
| || IVB ||Distant metastatic disease |
TREATMENT OF CERVICAL CANCER
Treatment is dependent on the stage of cervical cancer. Early stage cancer can often be treated with surgery alone and more advanced stages are treated with a combination of chemotherapy and radiation.
Microinvasive cervical cancer can be treated with a simple hysterectomy or if the patient desires fertility a large cold knife conization.
Radical hysterectomy is the surgical treatment of most stage IA-IB1 (sometimes stage IB2 and IIA1) cervical cancer. It involves removing the uterus, cervix, adjacent parametrial tissue and some of the vagina. The ovaries do not necessarily have to be removed during a hysterectomy; this decision depends on your age and other factors. Pelvic lymph node dissection is performed at the time of surgery to look for metastatic disease. This procedure can be done either open with a large abdominal incision or minimally invasively dependent on the patient. Occasionally, the radical hysterectomy is aborted if significant metastatic disease is found in lymph nodes. PET/CT scans prior to surgery can help us identify most of these patients with involved lymph nodes prior to surgery.
Radiation treatment with chemotherapy is used for the treatment of more advance cervical cancers. There are two ways we deliver radiation therapy in the setting of cervical cancer: external beam radiation therapy (EBRT) and brachytherapy. External beam radiation therapy (EBRT)
— With external beam radiation therapy (EBRT), the source of the radiation is outside the body, and the area to be treated (referred to as the radiation "field") is designed carefully to limit the amount of radiation directed at healthy tissue.
During EBRT, your body is positioned beneath the x-ray machine in the same way every day, and the radiation field is exposed to the radiation beam for a few seconds (similar to having an x-ray) once per day, five days per week for five to six weeks. This is done as an outpatient, and you can usually continue your normal daily activities during treatment. Brachytherapy
— Brachytherapy delivers radiation from a device that is temporarily placed inside the vagina. This delivers a high dose of radiation to the area where cancer cells are most likely to be found, hopefully minimizing the effects of radiation on healthy tissues.
There are two types of vaginal brachytherapy: low dose rate and high dose rate.
Low dose rate brachytherapy uses a device that delivers radiation through the vagina for two or three days, 24 hours per day. You stay in the hospital during this treatment.
High dose rate brachytherapy also uses a device that delivers radiation through the vagina. However, the device is placed in the vagina for only for a few minutes at a time once a day, and treatment is generally repeated three to five times. This treatment is generally given as an outpatient, and women who get high dose rate brachytherapy do not have to stay in the hospital overnight.
— Most women who undergo EBRT for cervical cancer are given chemotherapy during the radiation as chemotherapy has the ability to enhance the damaging effect of radiation therapy on cervical cancer cells; when chemotherapy drugs are used in this manner, they are referred to as "radiation sensitizers". The chemotherapy is usually given in a vein (IV) once per week during the course of EBRT. The typical chemotherapeutic drug given is Cisplatin.
FOLLOW-UP AFTER TREATMENT
After treatment patients are watched closely for the next 5 years. Recommended follow-up is every 3 months for the first 2 years then every 6 months until 5 years for completion of treatment; annual examinations thereafter.
Visits will include a physical examination with a pelvic examination. Pap smears are recommended every 6 months to annually. There is no data to support routine CT scans or PET/CT scans. These are recommended only when a patient has recurrence suspected.