Cancer of The Cervix
The cervix is the lower end of the uterus, which extends into the vagina. Of cancers of the female reproductive system, cervical cancer (cervical carcinoma) is the second most common in all women and the most common in younger women. It usually affects women between the ages of 35 and 55. This cancer may be caused by a virus (human papillomavirus) which may be transmitted during sexual intercourse.
Risk for cervical cancer seems to increase as a woman's age at first sexual intercourse decreases and as the number of sexual partners increases. Failure to have regular Pap tests also increases risk.
About 85 percent of cervical cancers are squamous cell carcinomas, which develop in the scaly, flat, skinlike cells covering the outside of the cervix. Most other cervical cancers develop from gland cells (adenocarcinomas) or a combination of cell types (adenosquamous carcinomas).
Cervical cancer can penetrate deep beneath the surface of the cervix, enter the rich network of small blood and lymphatic vessels that line the inside of the cervix, and then spread to other parts of the body. In this way, the cancer can spread to distant areas as well as to areas near the cervix.
Symptoms and Diagnosis
Symptoms may include spotting between periods or bleeding after intercourse. A woman may not experience any pain or symptoms until the late stages of the disease, but routine Pap tests can detect cervical cancer early. Cervical cancer starts with slow, progressive changes in normal cells and may take several years to develop. The progressive changes can be seen through a microscope on slides containing cells taken during the Pap test. Pathologists have described these changes as stages ranging from normal to invasive cancer.
The Pap test can accurately and inexpensively detect up to 90 percent of cervical cancers, even before symptoms develop. Consequently, the number of deaths from cervical cancer has been reduced by more than 50 percent since Pap tests were introduced. Doctors often recommend that women have their first Pap test when they be- come sexually active or reach the age of 18 and that the test be performed annually. If their test results have been normal for 3 consecutive years. women may schedule Pap tests every 2 or 3 years as long as they don't change their lifestyle. If all women had Pap tests on a regular basis, deaths from this cancer could be eliminated. However, almost 40 percent of American women aren't tested regularly.
If a growth, sore, or other suspicious area is seen on the cervix during a pelvic examination or if a Pap test shows an abnormality or cancer, the doctor performs a biopsy (removing a sample of tissue for examination under a microscope). The tissue sample is usually removed during colposcopy, in which the doctor uses a viewing tube with a magnifying lens (colposcope) to examine the cervix carefully and to choose the best biopsy site. Two different types of biopsy are performed: punch biopsy, in which a tiny piece of the cervix, viewed and selected with the colposcope, is removed; and endocervical curettage, in which tissue that can't be viewed is scraped from the canal of the cervix. Both types cause little pain and a small amount of bleeding, and the two together usually provide enough tissue for a pathologist to make a diagnosis. If the diagnosis isn't clear, the doctor performs a cone biopsy, in which a larger piece of tissue is removed. Usually, this biopsy is performed with the loop electrosurgical excision procedure (LEEP) in the doctor's office.
If the woman has cervical cancer, the next step -is to determine its exact size and locations-a process called staging. Staging begins with a physical examination of the pelvis and a variety of tests (cystoscopy, chest x-ray, intravenous urography, sigmoidoscopy) to find out whether -the cervical cancer has spread to adjoining struc-tures or to more distant parts of the body. Other tests, such as a CT scan, barium enema, and bone and liver scans, may be performed, depending on -the woman's circumstances.
Treatment depends on the stage of the cancer. -If the cancer is confined to the outermost layer -of the cervix (carcinoma in situ), a doctor is often -able to remove the cancer completely by remov-ing part of the cervix with a knife or with the loop electrosurgical excision procedure. This treatment preserves a woman's ability to have children.
But because cancer can recur, doctors ad-vise women to return for examinations and Pap tests every 3 months for the first year and every 6 months after that. If a woman has carcinoma in situ and doesn't plan to have children, removal of the uterus (hysterectomy) may be recommended.
If the cancer is more advanced, hysterectomy plus removal of adjacent structures (radical hysterectomy) and lymph nodes is necessary. Normal, functioning ovaries in younger women are not removed. Radiation therapy is also highly effective for treating advanced cervical cancer that has not spread beyond the pelvic region. Although radiation therapy usually causes few or no immediate problems, it may irritate the rectum and vagina. Delayed damage to the bladder and rectum may result, and the ovaries usually stop functioning.
When the cancer has spread beyond the pelvis, chemotherapy is sometimes recommended. However, only 25 to 30 percent of those treated can expect any response, and the response is usually temporary.
Dr. Shafiul Alam Khan
The author is an ancologist practising at Manchester, UK.
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