Common types of cancer

Cervical Cancer

Common types of cancer

Cervical Cancer

What Is Cervical Cancer?

It is a cancer of the cervix. The cervix is the lowest part of the uterus that connects the body of the uterus to the vagina (birth canal).

Who Is at Higher Risk of Getting Cervical Cancer?

Infection with certain types of Human Papilloma Virus (HPV) is a known cause of cervical cancer. The infection is widespread, affecting up to 80% of the population. Most infections, fortunately, are transient and asymptomatic. However, the persistent infection in susceptible women lasts longer than six months and may lead to various pre-cancerous or eventually cancerous lesions.

Situations that promote persistent infection is more common amongst those: who started sexual activity before the age of 17 (<17-year-old)
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Who have multiple sexual partners

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With more than 7 pregnancies

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First delivery was before the age of 17

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Smoking

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Having a low socioeconomic status

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Immunosuppressed due to illness or medication

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Using oral contraceptives for more than 10 years (probably due to more sexual activities rather than the contraceptive itself)

What Can Be Done to Prevent Cervical Cancer?

Prevention / minimising risks of infection

Infection with HPV is widespread. However, only high risks or oncogenic Human Papilloma Virus (hrHPV) causes cervical cancer. The virus is spread through bodily fluids during sexual contact, which may occur without a penetrative sexual act.

Therefore, to reduce the risks of infection, lifestyle modification is essential. This includes:
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01

Practising a healthy sexual lifestyle, like a monogamous relationship

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02

Avoiding or minimising casual sexual encounters

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03

Using condoms to reduce risks of infection, especially in casual sexual exposure

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04

Get vaccination against HPV

Screening Test

Screening tests must be cheap, acceptable to the public, easy to perform with repeatable results, detect pre-cancerous stages and have suitable treatment modalities to prevent cancer development. Screening for cervical cancer, in a way, is a misnomer, as we do not wish to detect cancer after it has developed but the stages before that.

The long years from initial infection to cancer development provide an excellent opportunity to detect the pre-cancerous stage when curative treatment is easy to preserve reproductive function. Pap smear screening has been proven effective in the fight against the development of cervical cancer and the death arising from it.

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Sexually active women between the ages of 30 and 65 should be screened every three years. Women younger than 30 but have been sexually active for more than 5 years are also encouraged to do so. The two most common screening tests nowadays are the conventional cytology Pap smear and the newer HPV DNA testing.

Screening Test

Pap Smear

Dr George Papanicolaou developed the pap smear or Papanicolaou test in the 1940s. The purpose of this test is to identify abnormalities in cervical cells. This procedure is used to detect precancerous conditions that may lead to cancer.

The procedure is short and may cause slight discomfort but not painful. It involves collecting cells from the cervix and sending them to the laboratory for analysis. The procedure does not require the use of drugs or anaesthetics. A qualified doctor or a trained nurse performs it.

It will be necessary for you to undress from the waist down. You will be asked to lie on a couch in a closed room. The doctor or nurse will gently insert a small instrument called a speculum into your vagina to hold it open and expose the cervix for the procedure.

The cervix will be lightly wiped with a smooth wooden spatula or a small brush (cytobrush) to pick up cervical cells (360 degrees). The brush is then dipped into a collecting specimen bottle with a specific liquid reagent. It is sent to the laboratory for staining and examination under a microscope.

It is best to make an appointment for a Pap smear when you are not menstruating. Also, refrain from sexual activity, use spermicidal (a barrier method for contraception) or a lubricant jelly, or insert any form of medication into the vagina 24 hours before the test. It is also safe to do the test during pregnancy.

You will be informed of where and when the results will be available after the test. It usually takes 2 to 6 weeks, depending on the workload of the laboratories and clinics.

During the first two consecutive years, we recommend yearly testing if you are between the ages of 30 and 65 and are sexually active or have been sexually active. If both results are negative, we recommend that you undergo the test every three years.

In all government health clinics and hospitals, private clinics or hospitals, Federation of Family Planning Association of Malaysia (FFPAM), National Population and Family Development Board, and Ministry of Women and Family Development (NPFDB) clinics.

The result of a routine screening test may be reported and interpreted in a few ways:

  1. Normal cervical cells and endocervical cells.
    • Needs routine follow-up a smear in one or three years
  2. ASCUS (abnormal cells of uncertain significance)
    • Depending on your age presence of infection, you may be advised for a repeat Pap smear after treatment
  3. AGUS (abnormal glandular cells of uncertain significance)
    • You may need further evaluation of your cervix and uterine cavity
  4. LGSIL (Low-grade squamous intraepithelial lesion)
    • Depending on your age and the presence of infection, you may be advised for a repeat Pap smear after treatment or for colposcopy
  5. HGSIL (high-grade squamous intraepithelial lesion)
    • You will need a colposcopy to confirm the diagnosis and to rule out early cervical cancer

Your gynaecologist will explain and discuss the best way to investigate or manage your case.

Screening Test

HPV Testing

In both men and women, Human Papilloma Virus (HPV) is transmitted through skin-to-skin contact and via bodily fluids. There is no doubt that it is the most common sexually transmitted disease.

It is estimated that there are over 100 types of HPV viruses. These viruses can be classified as high-risk or low-risk. There are 14 types of HPV viruses that pose a high risk of causing cervical cancer and other cancers such as anal and throat cancer. A low-risk virus causes genital warts.

This test aims to detect and determine the type of virus present in the cervix.

The test is performed on the same collection fluid used during a Pap smear. No added procedure is necessary. It is just an additional laboratory test to detect and identify the type of HPV presence. In fact, a self-test kit is available nowadays that enables women to do it at home and send the sample to the laboratory.

If the test results are negative, you are very unlikely to have cervical cancer in the next 5 years. You can space out your repeat test in the next five years.

If the test is positive, your doctor will look at the result of the Pap smear. You may be asked to have a repeat test or for a colposcopy and /or cone biopsy.

Screening Test

Colonoscopy

It is an instrument with a magnifying glass that enables doctors to examine your cervix more closely. Your doctor may spray the cervix with some solution to show the abnormal area, and a biopsy may be taken if needed. The examination is painless. It may, however, be uncomfortable for some.

Screening Test

Cone biopsy / LLETYZ / LEEP

This is an extension of the colposcopy examination but involves taking a slightly larger cervical biopsy. It can be done as an outpatient, daycare case or inpatient under anaesthesia. This test determines very early stage 1A or 1B cases.

Management of Cervical Cancer

Diagnosis of cervical cancer

A cervical cancer diagnosis can only be made after a biopsy report is available. Pap smear cytology is not adequate to make a diagnosis and start treatment. The biopsy can be made via colposcopy-directed biopsy, cone biopsy, or direct biopsy of grossly abnormal cervix noted on simple visual examination.

Staging

Staging starts after the diagnosis is made. It is clinical staging with clinical examination, but nowadays, it involves advanced imaging like CT scans. The decision for the most appropriate treatment will be made after staging. Stage 1 is when the disease is confined to the cervix, stage 2 with some extension to the vaginal area, stage 3 to tissue beside the cervix (plus ureteric obstruction) and stage 4 is when the disease has spread to the bladder and liver.

Types Of Treatment

Treatment depends on the disease stage, the patient's age and parity and the desire for fertility.

EARLY STAGE 1A1 OR EVEN 1A2

May be adequately treated with a cone biopsy or simple hysterectomy.

STAGE 1B1

Usually needs a trachelectomy (preserves the uterine body) or a more radical hysterectomy.

STAGE 1B2 AND ABOVE TILL STAGE 2A

Usually need a Wertheim hysterectomy with pelvic node dissection. Only follow-up is necessary if the nodes are not involved with the tumour. Otherwise, a combination of pelvic chemoradiation therapy (CCRT) is essential.

LARGE 1B3 OR 2A / B

Generally have positive nodes. Therefore, they will need CCR post-surgery. Surgery may best be avoided in this stage to minimize side effects. However, your doctor will discuss the other option of downstaging with chemotherapy, followed by surgery. 

STAGE 2B, 3

and above are usually treated with CCRT alone without surgery.

Follow up post-treatment

Regular follow-up is necessary every 3-4 months initially. Your doctor will discuss the tests required during each follow-up, depending on your primary treatment modality.

Leading the Way in Cervix Care

The SJMC Cancer & Radiosurgery Centre has been recognised as an industry leader in cancer management. It was designed with this objective in mind to provide the highest possible care for patients.

This article is intended to provide the necessary information to assist you in managing your cancer. In no way should the contents of this article be construed as medical advice. You must consult a physician if you are contemplating any form of treatment.

The staff and doctors at the centre are dedicated to providing the highest quality of care to every patient. Whether patients are seeking preventive services or coping with therapy, their goal is to enhance their emotional and physical well-being. The facility also offers a variety of support groups and other services that can ease the daily burden of living with cancer.