Neuro-oncology: An Advancing Sub-Speciality In Neurosciences
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Cervical cancer or cancer of the cervix is cancer affecting the lowermost segment of the uterus (womb). It is the second most common cancer affecting women in the reproductive age-group of 15-44 years, the first one being breast cancer. In India, about 122,000 women are afflicted with cervical cancer each year, half of whom may be expected to succumb to the disease. Compared to this, just about 12,000 cases are seen annually in the US, of which 4,000 are likely to lose their life owing to the disease.
It is also among very few forms of cancer, for which a cause has been clearly identified, namely the Human Papilloma Virus (or HPV). However, it may take weeks or years for the HPV virus to show symptoms. Notably, as much as 70% of cervical cancer in India and elsewhere is known to be caused by HPV-16 and HPV-18. (This very important information led to the development of a cervical cancer vaccine targeted against these two main viral subtypes, thereby aiming at reducing the mortality and morbidity associated with cervical cancer) These facts throw up the possibility that the disease could be preventable in a lot of women, by simple implementation of prevention strategies against acquiring HPV infections, identification & treatment of HPV related cervical lesions, good reproductive hygiene and very importantly, administration of a cervical cancer vaccine (already available in the market).
Symptoms and signs
In the pre-cancerous stages and early stage cancer, there may hardly be any symptoms. At a slightly advanced stage, there could be abnormal vaginal bleeding such as bleeding in-between periods, bleeding after sexual intercourse, douching or after a pelvic examination. Other symptoms include a thick, foul smelling discharge through the vagina or pelvic pain not associated with menstrual periods.
Diagnosis of Cancer
The most effective way to detect cervical cancer is through regular Pap smear tests, along with tests for the HPV. The main advantage of Pap smear is that it can help to detect the changes in the cervix (pre-cancer) quite early before the development of cancer. In the event of an abnormal Pap smear, the doctor will usually conduct a more thorough investigation into your symptoms, and then perform a Colposcopy. This is an attempt to physically examine, whether there is a tumor growing inside your body. This pre-cancer is easily treatable by ablative procedures or a simple hysterectomy. A Pap smear can also detect cancer before its spread to the surrounding structures, when a planned radical surgery could cure the disease.
Albeit, the definitive test to confirm the presence of a cancer is biopsy from the cervix
This involves removing a tiny piece of tissue from the suspected organ and examining it under a microscope. Cervical Biopsy may be done by several methods which include:
1. Colposcopic biopsy: The tissue to be examined is removed under the guidance of a colposcope
2. Endocervical curettage: Using a special instrument known as a curette, the physician removes tiny bits of tissue from the part of the cervix nearest to the uterus. This portion is usually difficult to see through a colposcope.
3. Cone biopsy: Also known as conization, this involves removing a cone-shaped piece of tissue from the cervix. At a very early stage, it could also serve as a form of treatment, because the tissue removed might contain the entire cancerous tumor. Usual techniques for the cone biopsy include LEEP (Loop Electrosurgical Excision Procedure) and the cold knife cone Biopsy.
Stages of Cancer
The classification of stages of cervical cancer is based on three important factors, local growth of the tumor, involvement of nearby lymph nodes and spread to distant areas of the body.
Stage 1: The cancer is too small to be seen without a microscope. Also, there is no spread to the lymph nodes and obviously no distant spread (known as metastasis). The first is Stage 1a1, where the tumor is less than 3 mm deep and 7 mm wide. When the growth is between 3 mm and 5 mm deep but still below 7 mm wide, it is in Stage 1a2. This is followed by Stage 1b, where the tumor can be seen without a microscope but has still not spread to the lymph nodes or to distant organs.
Stage 2: In this stage, the cancer has grown locally into the vagina, and the immediate surroundings but still not reached the lateral pelvic wall. Sub-classification of Stage 2 depends on the tumor size, which could be as much as 4 cm in Stage 1B1 and > 4 cms in Stage 1B2
In Stage 3, the cancer spreads laterally upto the pelvic walls, or may involve the lower third of vagina or may encase the ureter and may cause hydronephrosis.
Stage 4: the tumor has largely spread to involve the other adjacent pelvic organs such as urinary bladder / rectum or has spread obviously to involve the para-aortic nodes or other distant sites of the body.
For the early stage cancer, that is Stage 1a and 1b, the recommended treatment is surgery. Surgery could mean radical hysterectomy (removal of uterus with surrounding tissue) or trachelectomy (removing the cervix, part of the vagina but not the uterus) depending on the precise staging of the tumor & need to preserve the fertility potential.
From stage 2B onwards, the primary modality of therapy would be Radiation along with chemotherapy. Chemotherapy with a gradually increasing dose of Cisplatin should be given along with radiotherapy. In more advanced cases, other drugs such as 5-Fluoro-Uracil may also be added to the treatment protocol.
In these cases, the main form of treatment is chemotherapy with Cis-platin along with radiation therapy for the pelvic region (mainly to relieve symptoms). If the disease has progressed to Stage 4, monoclonal antibodies such as Bevacizumab along with Paclitaxil and Topotecan may be used as additional first line therapy. If these prove inadequate, a second line comprising of docetaxel, gemcitabine, etc. would be the only option.
It is suggested that every woman should get themselves vaccinated against cervical cancer. Going through regular Pap Smear tests reduces the chance of the development of a tumor going unnoticed. Diagnosis at the right time is the key to the best possible treatment of cervical cancer.
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Anju Ghangurde @ScripAnjuG firstname.lastname@example.org
Cytecare Cancer Hospital with the