Early diagnosis and personalized treatment of cervical cancer has shown a higher percentage of a cure.
Gynecologists, radiation oncologists and medical oncologists need to work together in order to offer the patient the best possibility of a cure.
Treatment is personalised in order to achieve the best results. Characteristics of the patient and tumor are analyzed by specialists at iTAcC.
Cervical cancer is the leading cause of death from gynecological cancer worldwide. Almost half of the cases are in women between the ages of 35 and 55.
Ahead of breast cancer, cervical cancer is the leading cause of female cancer mortality in many third world countries. In developed countries the incidence has decreased markedly in recent decades due to the campaigns of prevention and early diagnosis carried out in these countries. Approximately 2,100 cases are diagnosed annually in Spain.
Premalignant changes occur in the cells of the cervix even years before final development of cervical cancer. These premalignant changes can be referred to in various ways; dysplasia or cervical intraepithelial neoplasia (CIN). Early diagnosis is important in order to treat the disease in its early stages for achieving a higher cure rate.
85% to 90% of cervical tumors are squamous cell carcinomas while the remainder are mainly adenocarcinomas or adenosquamous carcinomas.
Infection with human papillomavirus (HPV) is the most important risk factor associated with the development of cervical tumors. HPV can be detected in almost 100% of tumors of the uterine cervix. We know that there are about 100 different genotypes of HPV. Some types infect both male and female genitalia such as the HPV 16, 18, 45 and 56 among others, and can cause cancer in the cervix. Subtypes 16 and 18 are found in 70% of tumors.
These viruses are transmitted during sexual intercourse. The use of barrier methods does not completely protect against the spread of the virus. There is no effective treatment currently for infection by these viruses. The risk of developing cervical cancer can be lowered if the lesions produced by these viruses such as warts, papillomas, or any abnormal growths, are dealt with effectively.
Most women infected with HPV will not develop cervical cancer and the infection usually goes away without treatment. The virus is destroyed by a woman's immune system. HPV infection can be present for years without causing any symptoms.
Other recognized risk factors are:
- Beginning sexual activity at an early age. Intercourse before the age of 18 doubles the risk.
- The number of sexual partners.
- High-risk partners.
- History of sexually transmitted infections (chlamydia and genital herpes)
- A history of squamous intraepithelial neoplasia or vaginal cancer (HPV is also the origin of these in most cases)
- Immunosuppression as in the case of patients with human immunodeficiency virus (HIV).
Multiparous (3 pregnancies) and deliveries in early age (before age 20) women also have a higher incidence of these tumors.
An increased risk associated with consumption of tobacco has been described in some cases of cervical squamous tumors, but not cases of adenocarcinomas.
The risk of developing these tumors increases with the use of oral contraceptives for a period longer than five years.
Female partners of circumcised men have less risk of cervical cancer.
The HPV vaccine protects against infection by high-risk subtypes of the virus that can lead to cancer. It does not protect 100% from HPV or other sexually transmitted diseases so it should not replace gynecological checkups.
HPV infection is usually transient. When persistent over time it will become a high-grade intraepithelial neoplasia and eventually an invasive tumor will form an average of 15 years later. The vast majority of cervical tumors develop from premalignant changes in cells. There are two ways to avoid the disease: first, premalignant lesions are preventable and second, detect and treat them before these lesions worsen.
Cancer of the cervix is often asymptomatic in the initial stages. It is important to perform pelvic examinations annually, which in most cases catches this disease in the early stage of development. Sometimes the symptoms that a cervical tumor can cause are nonspecific and may also appear in other non-malignant diseases. For this reason at iTAcC a gynecological examination is recommended. These symptoms may be vaginal bleeding between periods and after menopause, changes in the characteristics of menstruation, pelvic pain and bleeding or pain during intercourse.
At iTAcC we are very involved in the prevention and early diagnosis of cervical cancer and we have a special unit for the evaluation of this disease. An in-house multidisciplinary team carries out the clinical and radiological diagnosis processes for each case.
It is a simple and painless test performed during a gynecological examination. It involves the removal of cells from the cervix and vagina identifying in most cases, the cellular abnormalities that precede the onset of cervical tumor. This test regularly reduces the risk of invasive cancer and its high rate of mortality. This test is recommended for women who are or have been sexually active, have not undergone a hysterectomy or have had cervical cancer or premalignant lesions, and are between the ages of 25 and 65. (European Community recommendation). The upper age limit depends on whether the last two smears are normal.
HPV DNA Testing
This laboratory test identifies the virus strain responsible for the infection in patients with signs of HPV found during a Pap smear. The HPV family includes dozens of viral variants that include different levels of risk (high, medium or low) that leads to cervical cancer.
Colposcopy and cervical biopsy
It is a procedure during which the cervix and vagina are examined with a small extended microscope (colposcope). It is used to identify the presence of abnormal areas on the cervix. A medical specialist may perform biopsies of these areas to be analyzed by a pathologist.
Examination under anesthesia
Sometimes a pelvic examination can be painful for the patient so it can be performed under general anesthesia. Biopsies can be taken during the examination.
A full examination of the pelvis must be done in patients with known or suspected cervical cancer to establish tumor size, if it is confined to the cervix or locally advanced. This means whether or not it has invaded adjacent organs such as the vagina, parametrium, bladder or rectum.
- A chest x-ray evaluates the lungs and rules out the presence of lymph rule out nodules.
- Computed tomography or scanner (CAT): This technique uses ionizing radiation. It helps to rule out the possibility that the tumor has affected other organs (metastasis) such as the lungs or liver. It also determines the degree of local infiltration the cervical tumor has or if the pelvic lymph nodes are affected.
- MRI (magnetic resonance imaging) of the pelvis is a noninvasive method that does not use ionizing radiation. It is the diagnostic tool that provides more anatomical detail in the study of the pelvis. It is used to evaluate the local extent of disease (tumor size, spread to surrounding structures and lymph node involvement).
- Positron emission tomography (PET): It is a test that is able to determine the activity of cells and helps in the diagnosis of disease spread, both locally and remotely.
- Intravenous urography: Intravenous urography visualizes the kidneys, bladder and ureters. It involves administering an intravenous contrast which reaches the urinary tract and bladder and helps to evaluate its possible involvement by the cervical tumor.
- Cystoscopy is done under general anesthesia and involves visualizing the interior of the bladder through a thin tube inserted through the urethra. This test determines if the bladder has been affected by the cervical tumor.
- Rectoscopy: It consists of observing the rectum through an endoscope in order to see if the cervical cancer has affected the rectum.
The most appropriate treatment is decided once the diagnosis of cervical cancer has been confirmed and the necessary tests have been done to determine the stage of the disease.
There are various treatments which can be carried out in patients with cervical cancer. Surgery, radiotherapy and chemotherapy, can be used in combination or alone. Coordination is the key for obtaining the best results. At iTAcC, a multidisciplinary team of gynecologists, general surgeons, urologists, radiologists, pathologists, geneticists, medical oncologists, radiation oncologists, work together in the diagnosis and treatment of cervical carcinoma cervical in a personalized way. Medical professionals trusted by the patient may be included on this team for collaborating in the overall treatment decision.
Different specialties work together closely in order to combine therapies and offer the patient the best chance of a cure.
The following techniques are used in the surgical removal of the tumor.
- Conization: A cone shaped portion of the cervix is removed. It can be used immediately for diagnostic (extended biopsy) and therapeutic purposes as in the case of early stage and in situ tumors which can be completely eliminated.
- The hysterectomy is the removal of the uterus (corpus and cervix) along with the surrounding tissue (parametrium) as well as the upper part of the vagina. A radical hysterectomy is often accompanied by a pelvic lymphadenectomy; in this case the fatty tissue surrounding the blood vessels of the pelvis which contains lymph nodes is removed. It is necessary on occasion to remove the fallopian tubes and ovaries as well during surgery. This is based on risk factors, age or the spread of the disease. This surgery is done normally through the vagina or by an abdominal incision (laparotomy). Presently the internationally accepted laparoscopic approach reduces admission time as well as the rate of postoperative complications.
Radiation therapy is a therapeutic method which involves the use of ionizing radiation targeted directly at the tumor tissue in order to remove the tumor. This treatment can also be used in combination with chemotherapy for cervical cancer since this makes tumor cells more sensitive to radiation therapy.
Radiation therapy may be used after or prior to surgery or in combination with chemotherapy depending on the histological type and spread of the tumor.
At iTAcC a team of specialists decides which treatment regimen is best suited in each particular case. This team has extensive experience in conducting treatments with intensity modulated radiation therapy (IMRT) and image guided radiotherapy (IGRT) which permits reducing the radiation dose received by healthy organs such as the rectum, bladder, small intestine and bone marrow while administering the correct dose to the region of the tumor or in the surgical bed.
Chemotherapy may be used before surgery to shrink the tumor (neoadjuvant) in combination with radiotherapy as a single treatment or after surgery (adjuvant).
Several drugs have proven effective in the treatment of cervical cancer. Specialists at iTAcC evaluate the need to administer a single drug treatment or chemotherapy (multiple drugs) within the context of international treatment protocols. Their decision is based according to the characteristics related to the patient and the stage of disease.
It has been shown to increase the sensitivity of tumor cells to radiation when used in combination with radiotherapy and thus able to improve local control and the survival rate of the patients.
The iTAcC team establishes a regimen of periodic checkups after the treatment program is completed. This will include various tests that will change over time with the objective of controlling the possibility of disease recurrence.
iTAcC has the means to monitor and control the progress of patients who have had cervical cancer in order to rule out the possibility of disease recurrence.
Follow up is done as in the case of all oncological work at iTAcC in a personalized manner in cooperation with physicians who have been involved in the diagnosis and treatment of each case.