Cervical cancer is malignant cancer that forms in tissues of the cervix (the organ connecting the uterus and vagina). There are many types of cervical cancer. The most common type, squamous cell carcinoma (SCC), constitutes about 80 to 85 per cent of all cervical cancers. Human Papilloma Virus (HPV) infection is a necessary “ingredient” in the development of this cancer. The other types of cervical cancer, such as adenocarcinoma, small cell carcinoma, adenosquamous, adenosarcoma, melanoma and lymphoma, are much rarer types of cervical cancer that are not generally related to HPV. The latter types of cervical cancer are not as preventable as SCC.
Signs and Symptoms
Early cervical cancer has no symptoms.
See a doctor immediately when you experience the following late cervical cancer symptoms:
- Vaginal bleeding
- Back pain
- Painful or difficult urination and cloudy urine
- Chronic constipation and feeling of presence of stool despite having emptied bowel
- Moderate pain during sexual intercourse and vaginal discharge
- Single swollen leg
- Leaking of urine or faeces from the vagina
Carcinoma in Situ (CIS or CIN)
Carcinoma in situ (CIN) is a cluster of malignant precancerous cells that is still “in situ” or “on site” and has not moved from its original position and spread to other parts of the body yet. Fortunately, in Singapore and other developed countries, the widespread use of cervical screening programmes has reduced the incidence of invasive cervical cancer.
Pap smears can identify CIN of the cervix, where treatment can prevent the development of cancer. It is recommended that women get Pap smears once a year from the year that a woman engages in her first sexual intercourse, and continue till they are about 70. If two to three Pap smears are normal, women can consider reducing the frequency to once every two to three years. However, high risk ladies (see below) are advised to continue yearly.
Not all ladies with HPV infections develop CIN, and not all ladies who have CIN develop cervical cancer. Many HPV infections are cleared rapidly by the immune system, just like any other infections.
However, certain strains of HPV tend to stay in the cervix for many years, changing the genetic make up of the cervical cells, and leading to dysplasia (abnormal development of cells). In time, if left untreated, the severe dysplasias can and will usually develop into invasive cervical cancer.
CIN usually produces no symptoms at all. This would be the best time to screen for cancer as treatment at this time will almost always lead to a complete cure.
What causes this cancer and who is at risk?
Infection with Human Papilloma viruses (HPV) is the most common cause or risk factor for cervical cancer. These viruses are transmitted during sexual intercourse, as well as via oral or anal sex.
All women who engage in sexual activity are at risk of developing cervical cancer. However, women who have many sexual partners (or whose sexual partners have had many other partners) have a greater risk. Women who start unprotected sexual intercourse before the age of 16 are at the highest risk.
Vaccines have been developed that are effective against the strains of HPV responsible for 70 to 85 per cent of all cervical cancers. HPV vaccines are targeted at girls and women of ages nine to 26 because the vaccine only works if given before infection occurs. However, it can still be given to ladies who start their sexual activities much later. The high cost of this vaccine has been a cause for concern. However, since the vaccine only covers some high risk types, women should have regular Pap smears, even after vaccination.
Diagnosis & Assessment
While the Pap smear is an effective cervical cancer screening test, confirmation of the diagnosis of cervical cancer or pre-cancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acidic solution to highlight abnormal cells on the surface of the cervix. It is a painless 15-minute outpatient procedure.
Further diagnostic procedures include Loop Electrical Excision Procedure (LEEP), cone biopsies, and punch biopsies.
Treatment & Care
Staging and Treatment of cervical cancer
The Federation of Gynecology and Obstetrics (FIGO) classifies cervical cancer based on scans into CIN I to III, where CIN III is the immediate pre-cursor to cervical cancer. Beyond CIN III, it means the cells have turned into cancer, and will be graded from stages 0 (where cancer is confined only to the skin area) to 4B (where there is advanced distant spread).
Early stage 1 patients can be treated with conservative surgery for women who want to preserve their fertility, while the rest would be advised to remove the entire uterus and cervix (trachelectomy). It is generally recommended to wait at least one year before attempting to become pregnant after surgery. Due to the possible risk of cancer spread to the lymph nodes in late stage 1 cancer, the surgeon may also need to remove some lymph nodes from around the uterus for pathologic evaluation.
Recurrence in the residual cervix is very rare if the cancer has been cleared with the trachelectomy. Yet, it is recommended for patients to practise vigilant prevention and follow-up care including Pap screenings.
Early stage tumours can be treated with radical hysterectomy (removal of the uterus) with lymph node removal. Radiation therapy with or without chemotherapy may be given after surgery to reduce the risk of relapse. Larger early stage tumours may be treated with radiation therapy and chemotherapy. Hysterectomy may follow to provide better local cancer control.
Advanced stage tumours (stages 2B to 4B) will have to be treated with chemo-radiation therapy.
What are the chances of survival?
With treatment, the 5-year cervical cancer survival rate is 92 per cent for the earliest stage, 80 to 90 per cent for stage 1 cancer, and 50 to 65 per cent for stage 2. Only 25 to 35 per cent of women with stage 3 and less than 15 per cent with stage 4 cervical cancer are alive after 5 years. Therefore, early screening and detection of cervical cancer is critical.
What kind of support is available?
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