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Cervical cancer

Description:
Cervical cancer is a type of cancer that occurs in the cells of the cervix — the lower part of the uterus that connects to the vagina. It is due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Early on, typically no symptoms are seen. Later symptoms may include abnormal vaginal bleeding, pelvic pain or pain during sexual intercourse. While bleeding after sex may not be serious, it may also indicate the presence of cervical cancer.

Human papillomavirus infection (HPV),a sexually transmitted infection causes more than 90% of cases; most people who have had HPV infections, however, do not develop cervical cancer. Other risk factors include smoking, a weak immune system, birth control pills, starting sex at a young age, and having many sexual partners, but these are less importan. It typically develops from precancerous changes over 10 to 20 years. About 90% of cervical cancer cases are squamous cell carcinomas, 10% are adenocarcinoma, and a small number are other types.

When exposed to HPV, the body’s immune system typically prevents the virus from doing harm. In a small percentage of people, however, the virus survives for years, contributing to the process that causes some cervical cells to become cancer cells.

Worldwide, cervical cancer is both the fourth-most common cause of cancer and the fourth-most common cause of death from cancer in women.

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One can reduce the risk of developing cervical cancer by having screening tests and receiving a vaccine that protects against HPV infection.

Signs and symptoms:
The early stages of cervical cancer may be completely free of symptoms. Vaginal bleeding, contact bleeding (one most common form being bleeding after sexual intercourse), or (rarely) a vaginal mass may indicate the presence of malignancy. Also, moderate pelvic pain during sexual intercourse,between periods or after menopause and watery, bloody vaginal discharge that may be heavy and have a foul odor are symptoms of cervical cancer. In advanced disease, metastases may be present in the abdomen, lungs, or elsewhere.

Symptoms of advanced cervical cancer may include: loss of appetite, weight loss, fatigue, pelvic pain, back pain, leg pain, swollen legs, heavy vaginal bleeding, bone fractures, and (rarely) leakage of urine or feces from the vagina. Bleeding after douching or after a pelvic exam is a common symptom of cervical cancer.

Causes:
It isn’t clear what causes cervical cancer, but it’s certain that HPV plays a big role. HPV is very common, and most people with the virus never develop cancer. This means other factors — such as the environment or lifestyle choices — also determine whether one will develop cervical cancer.

Some of the causes are:

  • Human papillomavirus (HPV):
    HPV types 16 and 18 are the cause of 75% of cervical cancer cases globally, while 31 and 45 are the causes of another 10%.

Women who have sex with men who have many other sexual partners or women who have many sexual partners have a greater risk.

Of the 150-200 types of HPV known, 15 are classified as high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82), three as probable high-risk (26, 53, and 66), and 12 as low-risk (6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and CP6108).

Genital warts, which are a form of benign tumor of epithelial cells, are also caused by various strains of HPV. However, these serotypes are usually not related to cervical cancer. Having multiple strains at the same time is common, including those that can cause cervical cancer along with those that cause warts. Infection with HPV is generally believed to be required for cervical cancer to occur.

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*Smoking:
Smoking has also been linked to the development of cervical cancer. Smoking can increase the risk in women a few different ways, which can be by direct and indirect methods of inducing cervical cancer. A direct way of contracting this cancer is a smoker has a higher chance of cervical intraepithelial neoplasia (CIN3) occurring, which has the potential of forming cervical cancer. When CIN3 lesions lead to cancer, most of them have the assistance of the HPV virus, but that is not always the case, which is why it can be considered a direct link to cervical cancer. Heavy smoking and long-term smoking seem to have more of a risk of getting the CIN3 lesions than lighter smoking or not smoking at all. Although smoking has been linked to cervical cancer, it aids in the development of HPV, which is the leading cause of this type of cancer. Also, not only does it aid in the development of HPV, but also if the woman is already HPV-positive, she is at an even greater likelihood of contracting cervical cancer.

*Oral contraceptives:
Long-term use of oral contraceptives is associated with increased risk of cervical cancer. Women who have used oral contraceptives for 5 to 9 years have about three times the incidence of invasive cancer, and those who used them for 10 years or longer have about four times the risk.

*Multiple pregnancies:
Having many pregnancies is associated with an increased risk of cervical cancer. Among HPV-infected women, those who have had seven or more full-term pregnancies have around four times the risk of cancer compared with women with no pregnancies, and two to three times the risk of women who have had one or two full-term pregnancies.

Diagnosis:

Screening:
It includes the following:
*Pap test. During a Pap test, your doctor scrapes and brushes cells from your cervix, which are then examined in a lab for abnormalities.

A Pap test can detect abnormal cells in the cervix, including cancer cells and cells that show changes that increase the risk of cervical cancer.

*HPV DNA test. The HPV DNA test involves testing cells collected from the cervix for infection with any of the types of HPV that are most likely to lead to cervical cancer.

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Biopsy:
Confirmation of the diagnosis of cervical cancer or precancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix, with visual contrast provided by staining the normal tissues a mahogany brown with Lugol’s iodine. Medical devices used for biopsy of the cervix include punch forceps. Colposcopic impression, the estimate of disease severity based on the visual inspection, forms part of the diagnosis. Further diagnostic and treatment procedures are loop electrical excision procedure and cervical conization, in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe cervical intraepithelial neoplasia.

Often before the biopsy, the doctor asks for medical imaging to rule out other causes of woman’s symptoms. Imaging modalities such as ultrasound, CT scan, and MRI have been used to look for alternating disease, spread of the tumor, and effect on adjacent structures. Typically, they appear as heterogeneous mass on the cervix.

Interventions such as playing music during the procedure and viewing the procedure on a monitor can reduce the anxiety associated with the examination.

Precancerous lesions:
Cervical intraepithelial neoplasia, the potential precursor to cervical cancer, is often diagnosed on examination of cervical biopsies by a pathologist. For premalignant dysplastic changes, cervical intraepithelial neoplasia grading is used.

The naming and histologic classification of cervical carcinoma precursor lesions has changed many times over the 20th century. The World Health Organization classification[48] system was descriptive of the lesions, naming them mild, moderate, or severe dysplasia or carcinoma in situ (CIS). The term cervical intraepithelial neoplasia (CIN) was developed to place emphasis on the spectrum of abnormality in these lesions, and to help standardize treatment. It classifies mild dysplasia as CIN1, moderate dysplasia as CIN2, and severe dysplasia and CIS as CIN3. More recently, CIN2 and CIN3 have been combined into CIN2/3. These results are what a pathologist might report from a biopsy.

These should not be confused with the Bethesda system terms for Pap test (cytopathology) results. Among the Bethesda results: Low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL). An LSIL Pap may correspond to CIN1, and HSIL may correspond to CIN2 and CIN3, but they are results of different tests, and the Pap test results need not match the histologic findings.

Staging:…….CLICK & SEE THE PICTURES
Cervical cancer is staged by the FIGO system, which is based on clinical examination, rather than surgical findings. It allows only these diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton, and cervical conization.

Prevention:…….CLICK & SEE THE PICTURES
Checking cervical cells with the Papanicolaou test (Pap test) for cervical pre-cancer has dramatically reduced the number of cases of, and mortality from, cervical cancer. Liquid-based cytology may reduced the number of inadequate samples. Pap test screening every three to five years with appropriate follow-up can reduce cervical cancer incidence up to 80%. Abnormal results may suggest the presence of precancerous changes, allowing examination and possible preventive treatment, known as colposcopy. The treatment of low-grade lesions may adversely affect subsequent fertility and pregnancy. Personal invitations encouraging women to get screened are effective at increasing the likelihood they will do so. Educational materials also help increase the likelihood women will go for screening, but they are not as effective as invitations.

According to the 2010 European guidelines, the age at which to start screening ranges between 20 and 30 years of age, but preferentially not before age 25 or 30 years, and depends on burden of the disease in the population and the available resources.

In the United States, screening is recommended to begin at age 21, regardless of age at which a woman began having sex or other risk factors. Pap tests should be done every three years between the ages of 21 and 65. In women over the age of 65, screening may be discontinued if no abnormal screening results were seen within the previous 10 years and no history of CIN2 or higher exists. HPV vaccination status does not change screening rates.

A number of recommended options exist for screening those 30 to 65. This includes cervical cytology every 3 years, HPV testing every 5 years, or HPV testing together with cytology every 5 years. Screening is not beneficial before age 25, as the rate of disease is low. Screening is not beneficial in women older than 60 years if they have a history of negative results. The American Society of Clinical Oncology guideline has recommend for different levels of resource availability.

Pap tests have not been as effective in developing countries. This is in part because many of these countries have an impoverished health care infrastructure, too few trained and skilled professionals to obtain and interpret Pap tests, uninformed women who get lost to follow-up, and a lengthy turn-around time to get results. Visual inspection with acetic acid and HPV DNA testing have been tried, though with mixed success.

Barrier protection:
Barrier protection or spermicidal gel use during sexual intercourse decreases, but does not eliminate risk of transmitting the infection, though condoms may protect against genital warts.[64] They also provide protection against other sexually transmitted infections, such as HIV and Chlamydia, which are associated with greater risks of developing cervical cancer.

Vaccination:
Three HPV vaccines (Gardasil, Gardasil 9, and Cervarix) reduce the risk of cancerous or precancerous changes of the cervix and perineum by about 93% and 62%, respectively.[65] The vaccines are between 92% and 100% effective against HPV 16 and 18 up to at least 8 years.

HPV vaccines are typically given to age 9 to 26, as the vaccine is most effective if given before infection occurs. The duration of effectiveness and whether a booster will be needed is unknown. The high cost of this vaccine has been a cause for concern. Several countries have considered (or are considering) programs to fund HPV vaccination. The American Society of Clinical Oncology guideline has recommendations for different levels of resource availability.

Since 2010, young women in Japan have been eligible to receive the cervical cancer vaccination for free. In June 2013, the Japanese Ministry of Health, Labor and Welfare mandated that, before administering the vaccine, medical institutions must inform women that the ministry does not recommend it. However, the vaccine is still available at no cost to Japanese women who choose to accept the vaccination.

Nutrition:
Vitamin A is associated with a lower risk as are vitamin B12, vitamin C, vitamin E, and beta-Carotene.

Treatment:
Treatment for cervical cancer depends on several factors, such as the stage of the cancer, other health problems you may have and your preferences. Surgery, radiation, chemotherapy or a combination of the three may be used.

Surgery:
Early-stage cervical cancer is typically treated with surgery. Which operation is best for you will depend on the size of your cancer, its stage and whether you would like to consider becoming pregnant in the future.

Options might include:

*Surgery to cut away the cancer only. For a very small cervical cancer, it might be possible to remove the cancer entirely with a cone biopsy. This procedure involves cutting away a cone-shaped piece of cervical tissue, but leaving the rest of the cervix intact. This option may make it possible for you to consider becoming pregnant in the future.

*Surgery to remove the cervix (trachelectomy). Early-stage cervical cancer might be treated with a radical trachelectomy procedure, which removes the cervix and some surrounding tissue. The uterus remains after this procedure, so it may be possible to become pregnant, if you choose.

*Surgery to remove the cervix and uterus (hysterectomy). Most early-stage cervical cancers are treated with a radical hysterectomy operation, which involves removing the cervix, uterus, part of the vagina and nearby lymph nodes. A hysterectomy can cure early-stage cervical cancer and prevent recurrence. But removing the uterus makes it impossible to become pregnant.

Radiation:
Radiation therapy uses high-powered energy beams, such as X-rays or protons, to kill cancer cells. Radiation therapy is often combined with chemotherapy as the primary treatment for locally advanced cervical cancers. It can also be used after surgery if there’s an increased risk that the cancer will come back.

Radiation therapy can be given:

*Externally, by directing a radiation beam at the affected area of the body (external beam radiation therapy)

*Internally, by placing a device filled with radioactive material inside your vagina, usually for only a few minutes (brachytherapy)
Both externally and internally.

Radiation therapy might cause menopause. If one wants to consider becoming pregnant after radiation treatment, the doctor should be asked to preserve the eggs before treatment starts.

Chemotherapy:
Chemotherapy is a drug treatment that uses chemicals to kill cancer cells. It can be given through a vein or taken in pill form. Sometimes both methods are used.

For locally advanced cervical cancer, low doses of chemotherapy are often combined with radiation therapy, since chemotherapy may enhance the effects of the radiation. Higher doses of chemotherapy might be recommended to help control symptoms of very advanced cancer.

Immunotherapy:
Immunotherapy is a drug treatment that helps your immune system to fight cancer. Your body’s disease-fighting immune system might not attack cancer because the cancer cells produce proteins that make them undetectable by the immune system cells. Immunotherapy works by interfering with that process. For cervical cancer, immunotherapy might be considered when the cancer is advanced and other treatments aren’t working.

Supportive (palliative) care:
Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care.

Prognosis:
Prognosis depends on the stage of the cancer. The chance of a survival rate is nearly 100% for women with microscopic forms of cervical cancer. With treatment, the five-year relative survival rate for the earliest stage of invasive cervical cancer is 92%, and the overall (all stages combined) five-year survival rate is about 72%. These statistics may be improved when applied to women newly diagnosed, bearing in mind that these outcomes may be partly based on the state of treatment five years ago when the women studied were first diagnosed.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
https://en.wikipedia.org/wiki/Cervical_cancer
https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501
https://www.mayoclinic.org/diseases-conditions/cervical-cancer/diagnosis-treatment/drc-20352506

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