What is Cervical Cancer?
Cancer of the cervix is a preventable cancer because it is preceded by a long precancerous process. According to the two types of epithelium covering the cervix, histologically, cervical cancer is represented by squamous cell carcinoma (85-95%) and adenocarcinoma (5-15%). Cervical cancer can have exophytic (more common) and endophytic (less common) growth; endophytic forms have a worse prognosis.
Causes of Cervical Cancer
Risk factors for dysplasia and cervical cancer:
- early onset of sexual activity;
- early first pregnancy;
- a large number of sexual partners;
- history of sexually transmitted diseases;
- low social, household and cultural level of the patient and her partner;
- long-term use of oral contraceptives;
For adenocarcinoma of the cervical canal, one of the risk factors is exposure to diethylstilbestrol, which the patient took during pregnancy.
Patients at risk should be examined at least once every 6 months using extended colposcopy, cytological examination of smears, and, if necessary, using invasive examination methods.
Pathogenesis during Cervical Cancer
Depending on the prevalence, cervical cancer is divided into clinical stages.
- Stage 0 – cancer in situ.
- Stage I – The tumor is confined to the cervix.
– Ia – microinvasive cervical cancer, which is subdivided into:
– Iа1 – the depth of invasion is not more than 3 mm (metastases are observed in less than 1%);
– Iа2 – depth of invasion from 3 to 5 mm with a tumor diameter of up to 7-10 mm (frequency of metastases 4-8%);
– I6 – invasive cervical cancer (depth of invasion more than 5 mm).
- Stage II – a tumor that spreads beyond the cervix:
– IIa – infiltration of the upper and middle third of the vagina or the body of the uterus;
– II6 – infiltration of the parameters, not reaching the walls of the pelvis.
- Stage III – tumor outside the cervix (continuation of stage II):
– IIIa – infiltration of the lower third of the vagina;
– III6 – the spread of the infiltrate to the pelvic wall, infiltrate with hydronephrosis or secondary contracted kidney.
- Stage IV – the tumor invades adjacent organs or spreads beyond the pelvis.
– IVa – germination of the bladder or rectum;
– IV6 – distant metastases.
Cervical Cancer Symptoms
There are no clinical manifestations of the initial forms of cervical cancer (cancer in situ, microinvasive cancer). Pathognomonic for cervical cancer are contact bleeding, less often acyclic bleeding. However, the appearance of a bleeding usually corresponds to invasive cancer. Patients may complain of pus-like, foul-smelling discharge, pain (including in the lumbar region, kidneys), fever, weight loss, dysfunction of neighboring organs. As a rule, such symptoms correspond to inoperable and advanced forms of cancer. With advanced cancer, the diagnosis is made with a gynecological examination, with exophytic growth of a tumor on the cervix, growths like cauliflower of red, gray-pink or whitish color are visible, easily collapsing and bleeding when touched. When the tumor decays, a foul-smelling, pus-like or slop-colored discharge appears, and gray fibrin overlays are visible on the surface of the cervix. With endophytic growth, the cervix is enlarged, barrel-shaped, with an uneven, bumpy surface, and an uneven pink-marble color. Rectovaginal examination allows you to determine the infiltrates in the parametria, small pelvis.
In the initial forms, additional research methods are required (cytology, colposcopy, if necessary, a biopsy of the cervix). Colposcopic picture, suspicious of cervical cancer, includes pathological vessels, discoloration of the lesion, surface roughness, aceto-white epithelium, negative Schiller test. With adenocarcinoma, the clinical picture is more meager, and diagnosis is difficult, colposcopy in the initial stages is not informative. Changes in the cytological picture in the cervical canal or echographic signs of the pathology of the cervical canal require a more in-depth examination: hysterocervicoscopy, curettage of the cervical canal with histological examination of scraping, cone-shaped biopsy of the cervix.
To determine the stage of the process, sigmoidoscopy, cystoscopy, CT, MRI, angio- and lymphography are used.
Cervical Cancer Treatment
Treatment of cervical cancer includes the impact on the primary tumor (surgical, radiation) and the area of regional metastasis. Surgical treatment is possible only in stages I and IIa, it is carried out in combination with radiation therapy. The depth of invasion determines the likelihood of metastases to regional lymph nodes and recurrence of cervical cancer, which is taken into account when planning radiation therapy.
At stage 1a, in young women, the method of choice is high stab amputation of the cervix, and in patients over 50 years old – extirpation of the uterus with appendages.
At stage 1a2, young women undergo extirpation of the uterus with tubes, the ovaries are fixed in the region of the lower pole of the kidneys in order to remove them from the zone of subsequent irradiation with the preserved vascular pedicle. The rest of the patients undergo a panhysterectomy. In the future, radiation therapy is performed.
At stages I6 and IIa, Wertheim’s operation and combined (intracavitary and external) radiation therapy are performed, indications for preoperative radiation therapy are determined individually.
Nowadays, for operable cervical cancer in leading clinics, they have begun to perform surgery using laparoscopic access.
In stages IIb, IIIa, IIIb, only combined radiation therapy is performed.
In stage IV, palliative therapy is performed, but for distant metastases, chemotherapy with cystplatin is possible.
The prognosis for cervical cancer is determined by the stage of the disease, with stage I the 5-year survival rate is 70-85% both with surgical treatment and with radiation therapy (if surgery is contraindicated). At stage II, the 5-year survival rate is 40-60%, at stage III – 30%, at IV – less than 10%. The prognosis is significantly worse when a combination of cervical cancer and pregnancy. Thus, the 5-year survival rate at stage I during pregnancy decreases to 25-30%. However, in cured patients who have undergone initial forms of cancer and organ-preserving surgeries, subsequent pregnancy is not contraindicated.
Of the measures for the primary and secondary prevention of cervical cancer, the most applicable are the promotion of a healthy lifestyle, the formation and observation of risk groups, the timely detection and treatment of background and precancerous diseases of the cervix.
Familiarizing women and adolescents with contraceptive methods to prevent unwanted and early pregnancies, explaining the benefits of barrier contraception, promoting monogamous relationships, hygiene standards, anti-smoking advertising, etc. are aimed at creating a healthy lifestyle and weakening the action of harmful factors that contribute to the development of cervical cancer.
There is still no single point of view regarding dispensary observation in the world. Some authors believe that every woman should undergo colposcopy with cytological examination once every six months. Other clinicians pay attention to the economic cost and only perform colposcopy and cytology at risk. The first point of view is shared by Russian clinicians.