Published in Panorama
Early Detection and Good Prognosis
It was a good four years before 24 year old Shirin realized she was having low grade cervical intraepithelial neoplasia (CIN) or precancerous cervical cells when she went to her doctor for a pregnancy checkup. “Such a condition could have been detected much earlier with a simple Pap Smear Examination and treatment initiated with very good prognosis,” says Dr.Davinder Pal Kaur, Gynaecologist and Obstertrician, Zulekha Hospital, Sharjah.
Certical cancer, it is believed, is the second most common cancer in woman, globally and is a leading cause of cancer-related death in women in the less developed countries, next only to breast cancer. Dr.Kaur rues, “However, it is one of the cancers which can be detected very early and treatment given with very good results. Unfortunately, even here in the UAE, unlike breast cancer, the awareness of cervical cancer is hardly there. I would like to emphasize at the outset that it is imperative for every sexually active woman, no matter her age, how young or old, to undergo a Pap Smear Examination every three years, to detect precancerous cervical cells and rule out the possibility of these developing into cervical cancer proper.”
While the exact cause of cervical cancer is unknown, infection with two types of human papilloma virus (HPV), which is transmitted sexually, is certainly linked with the cancer and appears to be the primary risk factor. Also, human immunodeficiency virus (HIV) infection which reduces the immune system’s ability to fight infection, is believed to increase the likelihood of precancerous cells progressing to cancer. Certain studies indicate that women who smoke cigarettes are twice as likely to develop cervical cancer since the chemicals in the smoke are believed to increase the risk of damaging the cervical cells.
According to Dr.Kaur, there seems to be no hereditary factor involved in cervical cancer and the risk factors include early age at marriage, multi-parity or repeated pregnancies, women having multiple sexual partners and any sexually transmitted diseases. All these categories of women can become susceptible to cervical cancer, early.
Cervical cancer develops in the lining of the cervix, the lower part of the uterus that enters the vagina and the condition usually develops over time and may take as long as two to seven years to progress to an advanced stage. Explaining the course of the disease, Dr.Kaur elaborates, “In the very initial stages of the disease, the patient is almost totally Asymptotic, that is, she does not present any symptoms of the condition. We may view cervical can in two parts: one is the cervical cancer proper and the other is the cervical intraepithelial lesion or neoplasia which may be low grade or high grade. These refer to the abnormal changes in the cervical cells and are the precursors or the premalignant condition of the cancer proper. In this pre-malignant stage, most of the women would be asymptotic for a long period of time and only later they would develop some symptoms like post coital bleeding or excessive vaginal discharge. It may take as along as 5-7 years before this first symptom appears.”
Once malignancy takes hold, these women may occasionally feel foul smelling vaginal discharge or have intermenstrual spotting. Low back pain, painful urination and intercourse may be other symptoms. Cervical cancer which has spread to other organs may cause constipation and blood in the urine.
The disease usually progresses through four stages, explains Dr.Kaur. “During the early stage, it involves the cervix alone and then progresses to the vagina, uterus and finally the surrounding structures. The more it spreads, the more the surrounding tissues are involves. Then the distant spread starts, involving the lymph nodes. When this happens, the disease starts manifesting in a very virulent form. Once the disease progresses beyond a certain stage, the woman would start haemorrhaging and she would have heavy bouts of bleeding from the vagina and subsequently in the very advanced stages, it would involve the bladder and rectum. Again, I repeat, the focus should be early detection so that the women need not get to this kind of a stage at all.”
Invasive cervical cancer, the malignant form results when abnormally dividing cells present in the outer layer or epithelium, invade the deeper tissue layers. This mass of invading cells continue to divide and enlarge as it invades the surrounding tissues. Also, cells may break off from the primary tumour or mass and spread via the lymphatic or blood vessels to distant sites. The size and degree of invasion of the cancerous tissue will determine the stage of the disease, explains Dr.Kaur.
How is cervical cancer diagnosed? The Pap Smear Test is a cytological test for the cervix, explains Dr.Kaur. “This can detect the disease in its earliest manifestation and such a patient can be saved from the very sinister sequelae of the disease. This process involves visualization of the cervix with a speculum and sampling of the cells from the surface of the cervix. These cells are collected on a wooden spatula and fixed onto a glass slide and are subject to a staining process to detect the present of precancerous cells. If the cells are found to be abnormal, the next step is an examination called colposcopy. The cervix is viewed using a magnifying instrument, the colposcope which helps detect the area of the abnormal cells. Following this identification, a biopsy can be taken from there. These form the screening and diagnostic modes.”
“Our main concern with respect to the patients is that they are identified before they reach the invasive stage, to identify them in the premalignant stage, so that treatment is initiated since at this stage, the treatment is easier and also curative,” stresses Dr.Kaur.
Once such patients are identified, what is the treatment modality? “At no stage does medication have a role to play in cervical cancer - neither in the premalignant stage or in its cancerous form,” affirms Dr.Kaur.” The treatment at the premalignant stage involves local ablative therapy for the cervix. Also, the abnormal area of cervical tissue may be removed by loop diathermy which involves cutting the tissue with an electrically heated wire loop. This allows rapid and precise excision of the abnormal tissue. However, in cases where the abnormal tissue is large, laser vaporization therapy may be resorted to.
Continuing on the treatment modalities, Dr.Kaur says, “Proper surgical procedures come as Conization where a part of the cervix in the form of a cone is removed. However, there have to be specific individual indications for the treatment modality according to the patient s age, parity and degree of disease.”
Once diagnosed and treated, what is the prognosis for such patients? “It depends on the stage at which the disease is detected. In the early stages the prognosis or success of treatment is very good. The more advanced the disease, the more advanced the treatment, requiring complicated surgery and radiotherapy, the poorer the prognosis.”
What if a pregnant woman is diagnosed as having cervical cancer? Will it affect the foetus? Dr.Kaur explains, “We are doing the routine check for pregnant women, involving routine cervical examination. There have been instances reported, of pregnant women with cervical cancers. In that case we have to see; if it is a premalignant condition, we don t do anything to harm the pregnancy. The patient delivers and then we give her the specific treatment. Even in a malignant case, the baby is not affected but we have to decide on the treatment for the woman. If she is in very early stage of pregnancy we advise termination of the pregnancy. We then treat her for the malignancy. On the other hand, if she is already in the ninth month, as could be the case of women in some of the under developed countries who come to the hospital only for delivery and not for any ante natal check ups, we deliver the baby by Caesarian and then proceed to treat the mother for the malignancy.”
Cervical cancer is very much preventable and treatable with sound results if detected early and the need of the hour is spreading awareness of the simple Pap Smear Test to avoid pain and mortality from this menace.