Cervical cancer

Several risk factors for cervical cancer are linked to exposure to HPV, including:

HIV Infection

• Research shows that women with HIV have a higher risk of developing an infection from high-risk HPV types.

Multiple Sexual Partners

• Studies suggest that women with numerous sexual partners are at an increased risk of acquiring HPV, which may lead to cervical cancer. Multiple partners of the spouse can also contribute to the risk.

Prolonged Use of Oral Contraceptives

• Oral contraceptive pills are associated with an increased risk of cervical cancer. Research indicates that using oral contraceptives for five or more years can double the risk.

Smoking

• Smoking heightens the likelihood of developing precancerous cervical lesions (moderate or severe dysplasia) and increases the risk of cervical cancer.

Poor Hygiene Practices

• Failure to use sanitary napkins, neglecting vaginal hygiene, and not properly cleaning the genital area during washing can contribute to the risk of cervical cancer.

Weakened Immune System

• A compromised immune system, often due to immunosuppression, can increase the risk of HPV infection and subsequently cervical cancer.

Early stages of cervical cancer are typically asymptomatic and can be challenging to detect. The International Federation of Gynecology and Obstetrics (FIGO) stages cervical cancer as follows:

Stage 0:

Known as carcinoma in situ, this stage involves abnormal cells located in the innermost lining of the cervix.

Stage I:

This is an invasive form of cancer that remains confined to the cervix.

Stage Ia cervical carcinoma:

Preclinical invasive carcinoma that can only be detected under a microscope.

Stage Ib cervical carcinoma:

A clinically visible lesion that is still limited to the cervix.

• Stage Ib1: The tumor is no larger than 4.0 cm in diameter.
• Stage Ib2: The tumor exceeds 4.0 cm in diameter.

Stage II:

The cancer has spread locally beyond the uterus but has not reached the pelvic sidewall or the lower third of the vagina.

• Stage IIa cervical carcinoma: The cancer has extended into the upper two-thirds of the vagina without invading the parametrium (the fatty and connective tissue surrounding the uterus).
• Stage IIb cervical carcinoma: The cancer has spread into the parametrium but has not reached the pelvic sidewall.

Stage III:

The cancer has spread to the pelvic sidewall or the lower third of the vagina, and/or causes hydronephrosis or a non-functioning kidney due to ureter invasion.

• Stage IIIa cervical carcinoma: The cancer has extended into the lower third of the vagina but has not spread to the pelvic sidewall.
• Stage IIIb cervical carcinoma: The cancer has spread to the pelvic sidewall and/or caused ureter invasion, leading to hydronephrosis or non-functioning kidneys.

Stage IV:

The cancer has spread beyond the pelvis or invaded the mucosa of the bladder or rectum.

• Stage IVa cervical carcinoma: The tumor has extended into the mucosa of the bladder or rectum.
• Stage IVb cervical carcinoma: The cancer has spread beyond the true pelvis and/or metastasized to distant organs.

Early detection through cervical cancer screenings is key. To diagnose cervical cancer, several methods are used:

Physical Exam and Medical History

A complete physical examination is done to assess general health and look for signs of disease, such as unusual lumps. The doctor will also review medical history, health habits, and past illnesses or treatments.

Pelvic Exam

The pelvic exam involves inspecting the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. A speculum is inserted to examine the cervix for any abnormalities.

Pap Smear

A pap smear (or pap test) is a screening procedure to detect cervical cancer. Cells are collected from the cervix and examined for abnormalities.

Liquid-Based Cytology (LBC)

LBC is an advanced method for preparing cervical samples. The cells from the sample are suspended and a thin layer is spread on a slide for examination.

Visual Inspection with Acetic Acid (VIA)

This procedure involves applying acetic acid (vinegar) to the cervix to help detect precancerous changes.

HPV Testing

The HPV test detects the presence of HPV, the virus that causes cervical cancer, but does not confirm if cancer is present.

Computerized Screening

Computer-assisted image analysis and AI technologies are improving the sensitivity of pap smears by enhancing image pattern recognition.

Endocervical Curettage

This procedure involves using a curette to collect tissue from the cervical canal for microscopic examination.

Colposcopy

In this procedure, a colposcope (a magnifying device with a light) is used to examine the cervix and vagina for abnormalities. Tissue samples may be collected for further analysis.

Biopsy

If a pap smear reveals abnormal cells, a biopsy is performed to remove a tissue sample from the cervix for microscopic analysis.

Imaging

Imaging tests help determine the cancer’s location and whether it has spread. These include:

• CT Scan: Takes detailed images of the cervix after administering contrast medium to locate the tumor relative to surrounding structures.
• PET or PET-CT Scan: A PET scan, often combined with a CT or MRI scan, helps provide a comprehensive view of the area being studied.

There are over 100 types of HPV, with about a dozen of them linked to cancer. The two main steps in preventing cervical cancer are getting the HPV vaccine and adhering to regular screening guidelines from the American Cancer Society (ACS). These include:

Undergoing Cervical Screening

Detecting HPV types that can lead to cancer early is crucial for preventing cervical cancer. Regular screening tests are a reliable method to detect abnormal changes.

Getting the HPV Vaccine

The HPV vaccine helps prevent infection by protecting against the virus. These vaccines can prevent precancers and cancers of the cervix and are also approved for preventing other cancers, as well as genital and anal warts.

Note: India accounts for roughly 16% of the global cervical cancer deaths, but it can be prevented with vaccination.

Limiting Exposure to HPV

Encourage partners to discuss the HPV vaccine with their healthcare provider.

• Avoid sexual contact when visible warts are present.
• Limit the number of sexual partners.
• Avoid sexual relations with individuals who have had many partners.

Using Protection During Sex

Methods like condoms and dental dams help reduce the risk of contracting HPV during oral, anal, and vaginal sex.

Maintaining a Healthy Lifestyle

This can include eating more fruits and vegetables, regular exercise, quitting smoking, and taking certain supplements or vitamins as recommended by a healthcare provider.

Doctors to Visit

Cervical cancer care requires a multidisciplinary team of doctors. Those involved in diagnosing and planning treatment include:

• Gynecologist: A doctor specializing in female reproductive health.
• Gynecologic Oncologist: An expert in cancers of the female reproductive system who performs surgeries and prescribes chemotherapy.
• Radiation Oncologist: A doctor who uses radiation to treat cancer.
• Medical Oncologist: A specialist who uses chemotherapy and other medicines to treat cancer.

Questions to Ask Your Doctor

• What type of cervical cancer do I have?
• Has the cancer spread beyond the cervix?
• What is the stage of my cancer and what does that mean?
• Will additional tests be necessary before deciding on treatment?
• Should I consult with other doctors or specialists?

There are several treatment options for cervical cancer, including:

Surgical Procedures

• Conization: A procedure that removes a cone-shaped piece of abnormal tissue from the cervix.
• Hysterectomy: The surgical removal of the uterus. This can be:
• Simple hysterectomy: Removal of the uterus and cervix.
• Radical hysterectomy: Removal of the uterus, cervix, upper vagina, and surrounding tissues, including lymph nodes.
• Loop Electrosurgical Excision Procedure (LEEP): A treatment using an electrically heated wire loop to remove abnormal cells from the cervix and vagina.
• Exenteration: Performed if cancer recurs in the pelvis, this surgery removes the cervix, uterus, and ovaries.
• Radical Trachelectomy: A procedure that removes the cervix, surrounding tissue, and lymph nodes while preserving fertility by attaching the uterus to the remaining vagina.
• Bilateral Salpingo-Oophorectomy: Removal of both ovaries and fallopian tubes, often done with a hysterectomy.

Radiation Therapy

High-energy X-rays or particles are used to destroy cancer cells. Radiation may be applied alone, before surgery, or to shrink the tumor before surgery. Types of radiation therapy include:

• External-Beam Radiation Therapy: Delivered from a machine outside the body.
• Internal-Beam Radiation Therapy (Brachytherapy): Radiation is applied directly to the tumor using implants.

Note: For early cervical cancer stages, a combination of radiation and low-dose weekly chemotherapy is often used to enhance the effectiveness of treatment.

Chemotherapy

Chemotherapy involves drugs that target and destroy cancer cells by inhibiting their growth and division. Common chemotherapy drugs include:

• Cisplatin
• Carboplatin
• Paclitaxel (Taxol)
• Topotecan

Targeted Therapy

This treatment targets specific genes, proteins, or the tissue environment that contribute to cancer's growth. It blocks cancer cell growth and spread while minimizing damage to healthy cells.

For recurrent or metastatic cervical cancer, platinum-based chemotherapy is combined with targeted therapy, including drugs like:

• Bevacizumab (Avastin)
• Bevacizumab-awwb (Mvasi)
• Bevacizumab-bvzr (Zirabev)
• Tisotumab Vedotin (HuMax-TF)

Immunotherapy

Immunotherapy strengthens the body's immune system to fight cancer. One such treatment is the immune checkpoint inhibitor Pembrolizumab (Keytruda), which is used for recurrent or metastatic cervical cancer after chemotherapy. It may also be used with chemotherapy, sometimes alongside Bevacizumab, for advanced cases of cervical cancer.

Complications typically arise in advanced stages of cervical cancer or due to the treatments, similar to those seen in other cancers. These may include:

• Kidney Failure: In later stages, cervical cancer can involve the kidneys, sometimes causing kidney failure due to the blockage of ureters.

• Hydronephrosis: The swelling of a kidney due to the buildup of urine, indicating advanced disease and often involving the parametria.

• Pain: As the cancer progresses, it can spread to nearby tissues, causing pain in the pelvic area or problems with urination.

• Lymphedema: Swelling caused by the accumulation of fluid in tissues, typically as a result of pelvic radiotherapy or lymph node removal.

• Blood Clots: Cervical cancer can make the blood thicker, increasing the risk of clot formation. Large tumors can also exert pressure on veins, promoting clot development.

• Fistulas: Abnormal connections that form between organs or blood vessels.

• Orbital Apex Syndrome (OAS) and Blindness: A rare condition linked to malignant mixed Müllerian tumors, OAS occurs when cancer spreads to the eye, damaging the optic nerve.

Before pursuing any alternative treatments, always consult with your medical team, as some may interfere with your primary treatment plan. Common alternatives include:

Naturotherapy

A holistic, plant-based approach that may complement conventional treatments. While not a substitute for standard care, it can enhance the effectiveness of chemotherapy and radiotherapy. Herbs that may help include:

• Curcumin (Turmeric)
• Ginger root (Adrak Ki Jadh)
• Holy basil (Tulsi)
• Green tea
• Grapes (Angoor)
• Broccoli
• Banana (Kela)
• Cabbage

Homeopathy

Considered a complementary method, homeopathy may help alleviate symptoms and improve overall well-being. It should always be used alongside conventional treatments and under medical supervision.

Acupuncture

Acupuncture is recommended for managing cancer pain, one of the most challenging symptoms for cancer patients. Studies have shown it can effectively manage pain with minimal side effects. However, more research is needed to assess its specific benefits for cervical cancer-related pain.

Certain herbs and spices have demonstrated potential in aiding cancer management, but they should never replace conventional treatments. Always consult with a healthcare provider before introducing any new remedies.

• Basil (Tulsi): Contains compounds that may exhibit anti-cancer effects.
• Clove (Laung): Contains eugenol, which has been investigated for its possible anti-cancer benefits.
• Garlic (Adrak): Rich in organosulfur compounds that are linked to a reduced risk of cancer.
• Rosemary (Gulmehendi): Contains antioxidants like carnosic acid and rosmarinic acid, which may have anti-cancer properties.
• Saffron (Kesar): Contains crocin, which shows potential in preventing cancer.

Cancer can affect every aspect of life—physically, emotionally, socially, and financially—posing challenges for both patients and their families. For some, the cancer may be chronic, requiring ongoing care. Here are tips for coping:

Palliative Care

Palliative care aims to improve quality of life during treatment by managing symptoms and providing emotional and non-medical support. It includes:

• Pain relief medication
• Nutritional adjustments
• Relaxation techniques
• Emotional and spiritual support
• Encouragement to engage in enjoyable activities

Regular Follow-ups

It’s essential for women treated for cervical cancer to continue with regular Pap tests, regardless of the type of treatment they received (surgery or radiation). Survivors should also be vigilant about other cancers, such as breast, lung, and colorectal cancer. Imaging tests may be conducted if symptoms or signs suggest cancer recurrence.

Managing Symptoms of Advanced Cancer

While advanced cervical cancer that has spread to other parts of the body (like the liver or lungs) is often incurable, treatments can control the cancer and alleviate symptoms.

Focusing on Emotional and Mental Well-being

Dealing with fear and anxiety related to cancer and treatment can be managed by:

• Discussing cancer concerns openly
• Sharing feelings with loved ones
• Gathering information about treatment options
• Recognizing physical limitations
• Managing relationships by communicating openly with a partner
• Addressing practical challenges like:
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• Financial strain
• Childcare
• Work-related issues

Managing the Financial Impact of Cancer Care

Cancer treatment can be financially overwhelming. Beyond the cost of treatment, unplanned expenses can also accumulate. To manage this, talk to a social worker who can assist in finding financial benefits or grants, helping with claims, and reducing financial strain.

Tips for Caregivers

• Offer emotional support and encouragement
• Understand the treatment process and its side effects
• Help manage symptoms and side effects
• Coordinate medical appointments and ensure timely medication
• Assist with personal care and hygiene
• Provide empathy, positivity, and a listening ear
• Help with household tasks and manage insurance and billing issues