Cervical Cancer

What causes cervical cancer and who is at risk?

HPV infection is the most common cause of cervical cancer. Since this virus can be transmitted through sexual intercourse, women who are sexually active have a higher risk of getting infected. Women who have multiple sexual partners, or whose sexual partner have had many other partners, are at greater risk. Women who start having unprotected sexual intercourse from a young age are also at higher risk.

HPV vaccine

Vaccines are effective against strains of HPV responsible for up to 85% of all cervical cancers. HPV vaccines are targeted at females from a young age, as the vaccine only works if given before infection occurs. However, the vaccine only covers certain high-risk types of HPV, and women are advised to have regular Pap smear tests even after vaccination.

• Vaginal bleeding or the presence of abnormal discharge
• Pain during sexual intercourse
• Lower back or pelvic pain
• Painful or difficult urination and cloudy urine
• Chronic constipation and feeling of presence of stools despite having gone to the toilet
• Leaking of urine or faeces from the vagina

Carcinoma in SITU (CIS or CIN)

Carcinoma in situ (CIN) is a group of harmful pre-cancerous cells that is still ‘in situ’ or ‘on site’ and has not moved from its original position, which means it has not spread to other parts of the body yet. In Singapore and other developed countries, the widespread use of cervical screening programmes has helped to detect CIN and hence reduced the cases of invasive cervical cancer.

The Pap smear test can identify CIN of the cervix, where treatment can stop the growth of cancer. It is advised that women get the test once a year after becoming sexually active. This practice should continue until they are 70 years old. If 2 – 3 Pap smear tests show normal results, the woman can reduce the frequency to once every 2 – 3 years. However, women who are at high risk should continue to undergo a Pap smear test every year.

Not all women with HPV infections develop CIN, and not all women who have CIN develop cervical cancer. Many HPV infections can be cleared by the immune system, just like any other infection.

However, certain strains of HPV can stay in the cervix for many years, changing the genetic make-up of the cervical cells over time and leading to dysplasia (abnormal development of cells). If left untreated, severe dysplasia can develop into invasive cervical cancer.

CIN usually produces no symptoms at all. This would be the best time to screen for cancer as treatment at this point tends to be the most effective.

Cervical cancer can be diagnosed early through regular screening. If you are sexually active, these tests should be performed every 3 years until the age of 30, and subsequently every 5 years if tests are normal.

Pap smear

A pap smear is a screening test used to detect precancerous or cancerous cells in the cervix before it progresses to invasive cervical cancer. It is a simple procedure done in the outpatient clinic and only takes about 10 – 20 minutes.

During a pap smear, the doctor will use a speculum to hold the vagina open. A soft brush is then used to collect some cells from your cervix which will be sent for review in a laboratory. A normal result means that no precancerous or cancerous cells were found in your cervix. If you have an abnormal result, your doctor will advise you to have more tests done.

It is best to avoid sexual intercourse for 24 hours before having a pap smear. You should also schedule your pap smear during days when you do not have your menstrual period.

Biopsy

While the Pap smear is an effective cervical cancer screening test, a biopsy is needed to confirm the presence of cervical cancer or pre-cancer. This can be done during a colposcopy, which is a painless, 15-minute outpatient procedure. A colposcope, a special magnifying instrument, will be used to aid the visual inspection of the cervix. During the procedure, the doctor will apply a diluted acidic solution such as vinegar to highlight any abnormal cells on the surface of the cervix. If there are any areas of suspicious cells, samples will be taken and sent to the lab for review.

These screening methods are used to detect precancer of the cervix – known as cervical intraepithelial neoplasia. If detected as a precancer, treatment is usually via a day surgical procedure and does not affect the patient’s fertility, as it involves removing only the diseased part of the cervix.

However, if there are symptoms, then it is more likely to be an abnormal growth rather than a precancerous condition. For diagnosis, you will need to see a gynaecologist for assessment for any obvious growth on the cervix which may need to be biopsied.

If there is indeed an early cancer proven on biopsy, then further testing is needed to determine the stage for treatment. This can include examination under anaesthesia, scopes and scans.

Early stage cancer surgery: Trachelectomy

Early stage 1 patients who want to keep their fertility may opt for conservative surgery. Otherwise, it is advisable for the patient to undergo surgery to remove the cervix and part of the vagina in a procedure known as trachelectomy. It is recommended to wait at least 1 year before attempting to conceive after surgery. Due to the possible risk of cancer spreading to the lymph nodes in late stage 1 cancer, the surgeon may have to remove lymph nodes from around the uterus for further examination.

Any return of the cancer in the remaining cervix is very rare if the cancer has been removed with a trachelectomy. However, patients should continue to be cautious in prevention and follow-up care, including undergoing regular Pap smear tests.

Radical hysterectomy (removal of the uterus)

Early stage tumours can be treated with radical hysterectomy (removal of the uterus) with lymph node removal. Radiation therapy with or without chemotherapy may be given after surgery to reduce the risk of the cancer returning.

Larger early stage tumours may be treated with radiation therapy and chemotherapy. Hysterectomy may follow to control the local cancer better.

Hysterectomy

Hysterectomy is a surgical procedure where the surgeon removes the uterus (womb). This procedure is usually done through a cut in the abdomen under general anaesthesia.

Other approaches to doing a hysterectomy include vaginal hysterectomy (where the uterus is removed through the vagina) and robotic-assisted laparoscopic hysterectomy (where the doctor makes a small incision to insert a viewing scope).

Advanced stage cancer treatment

Advanced stage tumours (stages 2B to 4B) are usually treated with chemo-radiation therapy.

What are the chances of survival for cervical cancer?

If detected early, the chances of surviving cervical cancer is as high as 92%. However, the survival rate dips greatly if the cancer is discovered and treated late. Therefore, early screening and detection of cervical cancer is critical.

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