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Cervical cancer
In the UK, cervical cancer is the second most common form of cancer in women under the age of 35, causing more than one thousand deaths a year. However, potential cases are increasingly being detected at an early stage, thanks to the NHS cervical screening programme that aims to monitor the health of the cervix, or the 'neck' of the womb. Finding out about any abnormalities in the cervix as early as possible can be life-saving, as effective treatments are available.
Human Papilloma Virus (HPV) causes 99% of cases
Cervical cancer affects the cells in the lining of the cervix. The cancer itself can take years to develop, and is preceded by abnormalities in the cells caused by the sexually-transmitted virus, Human Papilloma Virus (HPV). HPV is a very common infection which often has no serious consequences. However, sometimes an HPV infection will persist, leading to a long phase of pre-cancerous disease.
This disease is called Cervical Intraepithelial Neoplasia (CIN), and means that there are abnormal changes in some of the cells found in the cervix. Medical experts use a system of grades to refer to CIN. Where CIN is given a low grade (0 and 1) it is likely to cause little harm and will often go away of its own accord. On the other hand, a high grade CIN (2 to 4) is much more likely to develop into cervical cancer.
If CIN is detected by the screening programme it can be treated before the cancerous stage is ever reached. It is important to make the most of screening programmes, as both HPV and CIN have no apparent symptoms.
More about HPV
HPV is a very common virus that, in over 90% of cases, is cleared naturally by the immune system within months. There are forty different sub-types of the virus. Fifteen of these sub-types can lead to cervical cancer, and two of them (numbers 16 and 18) cause over 70% of cancer cases. Other sub-types can lead to common warts and genital warts, but the sub-types that cause warts do not lead to cancer. Becoming infected with one type of HPV does not increase the risk of infection with another.
HPV is a sexually transmitted infection (STI). This does not mean that infection is a sign of promiscuity. Anyone who has had a sexual relationship has exposed themselves to the possibility of infection, and estimates say that up to 75% of sexually active women will be infected with HPV at some point in their lives. In the majority of cases, this infection will go undetected and will not lead to cancer.
Unlike other STIs, HPV can be transmitted through skin-to-skin contact, even where no bodily fluids are exchanged. This means that sexual contact between women also presents a risk of infection, and that condoms cannot provide full defence in the case of penetrative sex.
Other lifestyle factors can affect the ability of your immune system to fight HPV infection. Eating a balanced diet and not smoking will help to give your body the best chance.
HPV vaccines
In late 2006, a vaccine was launched in the UK that can help to prevent cervical cancer, pre-cancerous cervical viruses and genital warts. The vaccine, which targets four types of HPV (6, 11, 16 and 18), gained its European licence in September 2006. It is aimed at young women aged 9-25. It is currently available for private purchase and on prescription from some GP practices; it might be available more widely on the NHS later in 2007, depending on NICE guidelines and local Primary Care Trust decisions.
A second HPV vaccine is also expected to be licensed in 2007 which protects against the strands leading to cervical cancer (16 and 18), but not against genital warts. This vaccine will be aimed at women aged 12-55, acknowledging that older women are also at risk. There is ongoing debate as to whether the vaccine should also be given to men and boys on the NHS, but there is not yet enough research about whether this is cost-effective in preventing cervical cancer.
Cervical screening
The NHS Cervical Screening Programme in England invites all women aged between 25 and 64 for regular tests, approximately once every three to five years1. There is no obligation to accept these invitations, and you may want to ask for more information. However, it is important to consider that regular screening detects up to 80% of cervical abnormalities, which may then be treated in time to prevent cervical cancer.
The primary method for cervical screening is now Liquid Based Cytology (LBC). LBC is replacing its precursor, the Smear Test or the Pap Smear2, which has been used for cervical screening in Britain since the mid-1960s.
Liquid Based Cytology takes a small sample of cells from the lining of the cervix using a small brush. The cell sample is then deposited in a preservative fluid in a small container. This container is then sent to a laboratory to be examined under a microscope.
In the laboratory, any mucus or blood can be separated out before the cells are deposited on to a slide. This helps to make sure that the test is accurate and means that fewer women have to come for a re-test. It also enables the laboratory to test for other sexually transmitted infections at the same time, including Chlamydia.
Like many screening procedures, LBC is not 100% effective, and some abnormalities may go undetected. This can be because the abnormal cells look very similar to the healthy cells, because the sample failed to pick up any abnormal cells, or because the person reading the slide failed to recognise the abnormality. An ‘abnormal' test result does not necessarily indicate that abnormal cells have been found, and a second test may be required to gain a more reliable result.
Diagnosing CIN
When a second screening result shows abnormalities in the cervical cells, the patient may be asked to go for a further test, called a colposcopy. This is a visual examination of the cervix, using an external microscope that does not penetrate the vagina. The doctor dabs different liquids onto the cervix to find the location of the abnormal cells. Diluted vinegar can be used, which turns abnormal cells white, or iodine, which turns healthy cells brown.
If abnormal tissue is found, the doctor may perform a biopsy, a minor procedure in which a small sample of cells are lifted from the cervix for further analysis. The biopsy allows a decision to be made as to whether treatment is needed. Early changes may get better on their own, so treatment may not be advised straight away. However, cell changes of CIN 2 and above are considered to be ‘pre-cancer' and are usually treated.
Treating CIN
The diagnosis of high-grade CIN, or ‘pre-cancer', can be a cause of much anxiety. The possibility of cancer is both an emotional and a physical strain. However, the early detection of a problem means a much higher possibility of successful treatment, and the treatment of CIN is both simple and effective.
There are two forms of treatment, known as ‘ablative' and ‘excisional'. Ablative therapy aims to destroy the pre-cancerous cells, while excisional therapy aims to remove them.
Cryotherapy is an example of ablative therapy. It exposes the abnormal cells to a sharp drop in temperature to prevent their survival. A refrigerant gas is applied to the cells via a very small probe, causing a small pain or cramp that has been compared to a bee-sting.
Loop electrosurgical excision procedure (LEEP) is an excisional technique that has the advantage of preserving the extracted tissue for further examination. A small electric current is applied around the periphery of the affected tissue, causing the cells to separate and be cut away.
Diagnosing cervical cancer
If the cells taken to be examined during a LEEP treatment for CIN show any signs of invasive cancer, further tests will be advised to see how far the cancer has developed and to decide upon the most appropriate method of treatment. Such tests can include pelvic examination, scans, blood tests and x-rays.
Going for tests and awaiting results is a very stressful experience. While some people choose to put the possibility of cancer to one side until a diagnosis is given, some will imagine the worst and feel very afraid. This can be a very lonely experience and it can be helpful to discuss your feelings with friends and family. There are also charities that provide personal support and advice. (Please consult the list at the end of this article.)
If you are diagnosed with cancer your first reaction may be one of shock. You may feel overwhelmed by the possible consequences. While it can help to ask questions about your condition and the recommended treatments, you may find it difficult to absorb the information. This is not unusual, and you should give yourself time to come to terms with the shock. You may also feel angry, helpless and frightened about the future. Extra rest may be needed to cope with the emotional and physical strain, and again it may help to spend time with family and friends.
Symptoms
As mentioned above, symptoms only occur once the HPV virus and the pre-cancerous disease CIN have developed into cancer. The most common symptom is irregular vaginal bleeding in between periods, during or after sex, or at any time following the menopause. Other symptoms include discomfort or pain during sex, and a vaginal discharge with an unpleasant odour.
Symptoms related to cervical cancer can also be the result of many other infections, and so they cannot be used for reliable diagnosis. It is worth seeking advice from a doctor if you are worried about any of these symptoms.
Stages of cervical cancer
The progress of cancer, or the extent to which it has spread, is usually referred to in numbered stages, 0 to 4. Grade 0 refers to the highest grade of pre-cancer, or CIN 3, so it is not yet cancer.
Grades 1 to 4 refer to where the cancerous area is and how far it has spread. Grade 4 refers to the most advanced stages of cancer, in which it has spread from the cervix to other organs.
Treatments
Coping with treatments can be another source of much stress, interrupting your lifestyle and obliging you to take more time to rest and to deal with any side effects. The three treatments most commonly prescribed are hysterectomy, radiotherapy and chemotherapy, and sometimes a combination of all three treatments is recommended. Here is some more information about what each treatment hopes to achieve, and how they are carried out.
Hysterectomy to remove cancerous tissue
When a cancer is detected at a relatively early stage, a hysterectomy can be recommended. This involves the removal of the cervix and the womb in order to remove all cancerous tissue. While this can be a successful way of getting rid of a cancer, the possibility of losing one's fertility can also be frightening and upsetting.
In some cases, it is possible to remove just the cervix so that future pregnancy is still possible, although the baby would need to be born by caesarean section.
If a full hysterectomy is needed, the womb is also removed, including the surrounding lymph nodes and the tissues that hold it in place. If the cancer is very advanced, other organs may need to be removed, such as the bowel, rectum or bladder. Although a hysterectomy may be life-saving, an operation to remove any organ can also be emotionally distressing and counselling should be made available.
Radiotherapy
Radiotherapy uses radiation to control the spread of cancerous cells. It can be carried out externally and/or internally. In external radiotherapy, radioactive beams are directed at the affected part of the body from a machine. The beams come from a number of different angles, and aim to cross each other at the location of the malignant cells, so that the surrounding tissues only come into contact with relatively weak beams. The treatment is usually given over a five-day week with a rest at weekends.
Internal radiotherapy places a source of radiation within the womb itself. This can be administered constantly for up to five days, during which the patient remains in a solitary ward, or in short treatments with overnight stays in hospital. Radiotherapy itself is painless, but side effects can occur, such as damage to surrounding tissues resulting in swelling or soreness.
The choice between external and internal radiotherapy can depend on the lifestyle of the patient and the position of the cancer. Internal radiotherapy allows a high dose to be delivered to a very specific location, while external therapy requires regular sessions during which smaller doses are administered.
Chemotherapy
Radiotherapy is often used in conjunction with chemotherapy, and the combined treatment is called chemoradiation. Research has shown that both radiotherapy and chemotherapy are more effective when they coincide. While radiotherapy aims to control the spread of cancerous cells, chemotherapy administers drugs that destroy their growth. These are called cytotoxic drugs. Chemotherapy can reduce the effect of advanced cervical cancer and relieve any related symptoms. Chemotherapy drugs can be given as an injection or in tablet form. Side effects related to chemotherapy will depend on which drug you are taking. Common side effects include a drop in the number of blood cells, diarrhoea, nausea, hair loss or thinning, feeling tired, and a sore mouth.
Living with cervical cancer
There is no easy way of learning to live with cancer. You may be encouraged to ‘think positively', but it is important not to deny your fears. Some people go through a form of depression. This does not mean that they are not being brave or failing to cope; rather, they are going through the difficult experience of facing up to a new, unexpected and unwanted situation.
Talking about your experience of cancer can also be difficult, however much it is recommended. If you are finding it difficult to talk to family and friends, remember that there are other sources of help and support.
Useful contacts
Aside from advice from your GP and your specialist consultant, many cancer support groups exist to help cancer patients and their families cope. Here are the contact details for a few of those support groups and places to get further information:
Jo's Trust
01327 341965
Macmillan Cancer Relief
0808 808 2020
Cancer Backup
0808 800 1234
Cancer Research UK
Sources
International Agency for Research on Cancer (IARC)
www.iarc.fr
Cancer Backup
www.cancerbackup.org.uk
Cancer Research UK
www.cancerresearchuk.org
NHS direct
www.nhsdirect.nhs.uk
References
1 There are minor differences in the functioning of NHS screening services in Scotland and Wales. For region-specific information consult www.nhs24.com for Scotland, and www.wales.nhs.uk for Wales.
2 'Pap' refers to George Papanicolaou (1883-1962) who developed the method of analysis for samples of cervical cells.
This factsheet is supported by an educational grant from Sanofi Pasteur MSD. It has been written and produced by Women's Health Concern and reviewed by one of our Medical Advisory Panel. Review date: April 2007.
© Women's Health Concern. Charity No. 279651
Telephone advice line: 0845 123 2319 (Mon-Tue 10am-2pm; Wed- Fri 10am-1pm)
Email advice: advice[at]womens-health-concern.org (NB: please type @ instead of [at] in your email)
Website: www.womens-health-concern.org
See also...
The following health information factsheets:
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