Cervical cancer is the second most prevalent cancer among women, globally and is the primary cause of cancer-related deaths in developing countries. Globally, over 5 lakh women are diagnosed with cervical cancer annually of which 1 lakh are from India.
There is a wide variation in incidence with urban population accounting for 40% and rural population accounting for 60% of cases. Middle-aged women, especially from lower socioeconomic status, are more prone to this. While mortality from cervical cancer has decreased by 75% in developed countries over the last 5 decades, it is not the same case in India, due to the lack of effective screening.
Human papillomavirus (HPV) infection, Immune system deficiency: Women with lowered immune systems have a higher risk of developing cervical cancer.
Herpes: Women who have genital herpes have a higher risk of developing cervical cancer.
Smoking: Women who smoke are about twice as likely to develop cervical cancer as women who do not smoke.
Age: People younger than 20 years old rarely develop cervical cancer. The risk goes up between the late teens and mid-30s. Women past this age group remain at risk and need to have regular cervical cancer screenings, which include a Pap test and/or an HPV test.
Socioeconomic factors: Cervical cancer is more common among groups of women who are less likely to have access to screening for cervical cancer.
Exposure to diethylstilboestrol (DES): Women whose mothers were given this drug during pregnancy to prevent miscarriage have an increased risk of developing a rare type of cancer of the cervix or vagina.
There are 2 kinds of prevention, Primary and secondary prevention.
Primary prevention: Identifying the early-stage cancers which prevent the progress of the disease. Pap smear and HPV testing are two methods for screening.
Screening: All women from 21-65 years age are recommended to undergo an office-based test called Pap smear every 3 years or Co-testing with pap smear + HPV test every 5 years. For women more than 65 years no screening is recommended if she was hysterectomised previously or had no CIN 2/3 lesion previously.
Secondary prevention: Preventing the development of pre-cancers, HPV vaccination, avoidance of smoking, avoidance of multiple sex partners and use of a condom.
HPV vaccine: Is recommended for both boys and girls beginning at age 11. It is approved to be used for 45 years but not recommended beyond 26 years because it is less effective. Cervarix and Gardasil are the two vaccines available. While Cervarix protects against 2 high-risk strains Gardasil-9 protects against 5 strains. The injection is intramuscular given as 2 doses of 0 and 6 months for those aged 11-15 years and 3 doses of 0,2,6 for those aged 15-26 years. Vaccinated women need to undergo the same screening protocol because vaccination is against high-risk strains and does not protect against disease caused by other strains.
There is a long natural course from pre-cancerous stages like CIN to cancer which takes 20 years. So, we have a 20 year period during which we can detect and offer treatment so that the survival reaches near 100%
Early diagnosis & Treatment
Early referral to an oncologist by primary care physicians of women with complaints of bleeding per vagina or white discharge per vagina or post-coital bleeding or abnormal pap smear. They need to undergo a biopsy and other tests for the staging of disease like CT/MRI/ PET scan. Treatment depends on the stage of the disease.
Early stages are treated with surgery and advanced stages need radiation or a combination of radiation and surgery and very advanced stages need chemotherapy.
Side effects of treatment:
Surgery has the following complications like bleeding, infection, injury to urinary and intestinal systems which are manageable.
Radiation has short term side effects like nausea, vomiting, skin changes, diarrhoea, fatigue, radiation cystitis, vaginal pain, menstrual changes, vulval and vaginal irritation. Long term effects like vaginal stenosis, dryness, weak bones and swelling of legs which are mostly self-limiting.
Chemotherapy has side effects like hair loss, mouth sore, loss of appetite, nausea, vomiting, diarrhoea and low blood count which are manageable.
It is recommended to follow-up with the treating doctor every 3 months for the first 2 years and every 6 months for the next 3 years and annually lifelong to identify recurrence early.
Depends on the stage of disease at presentation. The survival rate for localised disease is 90% while that for regional is 56% and metastatic disease has a survival of only 17%.
By Dr Revanth Gangasani, Consultant- Surgical Oncology, Aware Gleneagles Global Hospital, LB Nagar