Cervical cancer: Stages, Treatment and Prevention

Cervical cancer is a type of cancer that occurs in the cells of the cervix. Cervix is the the lower part of the uterus that connects to the vagina. Various strains of the human papillomavirus (HPV), a sexually transmitted infection, smoking, taking birth control pills can play a role in causing most cervical cancer.

Stages of Cervical cancer:

The extent to which the cancer has spread in the body at the time of diagnosis is called as the stage of a cancer. Staging can help determining the best treatment plan as well as the prognosis of an individual. According to FIGO (International Federation of Gynecology and Obstetrics) system and the AJCC (American Joint Committee on Cancer) system, staging of cervical cancer are based on the tumor extent, spread to any lymph nodes, and distant spread. Cervical cancer is classified in stages from 0 to IV, with many subcategories within each stage.
These include:

• Stage 0: This stage is not an invasive cancer. The abnormal cells are only on the surface of the cervix. This stage is not included in the FIGO system and is referred to as carcinoma in situ (CIS).
• Stage I: Tumor is present in a small amount that has not spread to any lymph nodes or distant sites.
• Stage II: The cancer has spread beyond the cervix and uterus, but does not invade the pelvic walls or the lower part of the vagina.
• Stage III: The cancer has grown into the lower part of the vagina or the walls of the pelvis. The tumor may be blocking the ureters. There is no spread to other sites in the body.
• Stage IV: This is the most advanced stage, in which the cancer has spread to the bladder or rectum, or to sites in other areas of the body, , such as the lungs, liver or bones.

Imaging tests such as X-rays, CT scans, magnetic resonance imaging (MRI) and positron emission tomography (PET) help your doctor determine whether your cancer has spread beyond your cervix.

Treatment for cervical cancer:

Treatment for cervical cancer depends on several factors, such as the stage of the cancer, other health problems you may have and your preferences.
Different doctors those are involved in the treatment team, include:

• Gynecologic oncologist, a physician who specializes in treating cancers of the female reproductive organs, including surgery to remove cancers
• Radiation oncologist, a physician who uses radiation to treat different kinds of cancer
• Medical oncologist, a specialist in the use of chemotherapy and other medical therapies to treat cancer

Treatment for precancerous lesions differs from that of invasive cervical cancer.

Precancerous lesions:

Choice of treatment for a precancerous lesion of the cervix depends on a number of factors, including whether the lesion is low or high grade, whether you want to have children in the future, your age and general health, and your preference.
If you have a low grade lesion detected by a Pap smear test, you may not need further treatment, especially if the abnormal area was completely removed during biopsy. You should have regular Pap smears and pelvic exams, as scheduled by your doctor. LEEP conization, cold knife conization, cryosurgery, cauterization, or laser surgery are the treatment options that may be used to destroy the abnormal area while minimizing damage to nearby healthy tissue when a precancerous lesion requires treatment. Cramping or other pain, bleeding, or a watery vaginal discharge are the most common side effects while treating a precancerous lesions.  
For some kind of precancerous changes you may choose to have a hysterectomy, particularly if abnormal cells are found inside the opening of the cervix or you have severe or recurring dysplasia. This surgery is more likely to be done if you do not plan to have children in the future.
Sometimes diagnostic procedures, such as LEEP and cold knife conization may treat the cervical precancer. These procedures involve taking tissue to evaluate. Only follow-up may be needed if the evaluation finds abnormal cells, but the cells do not extend into where the tissue was cut.
Further treatments may be required if there is uncertainty about whether all of the precancerous cells have been removed using LEEP or cold knife conization procedures.
Cryocautery may be used in some cases. In this procedure, a steel instrument is cooled to subzero temperatures by immersion in liquid nitrogen or a similar liquid. This ultracooled instrument is then applied to the surface of the cervix, freezing cells. They eventually die and are sloughed off, to be replaced by new cervical cells.
Laser ablation may also be used in some cases to remove the tissues. In this procedure, a laser beam is applied to either specific areas of cervical tissue or a whole layer of tissue at the surface of the cervix. The laser destroys these cells, leaving healthy cells in their place.
A follow-up examination and Pap smear are usually done to determine the success of cryocautery or laser ablation procedures. Biopsy is not done in both the procedure. They only destroy the abnormal tissue. Therefore, the margins or edges cannot be inspected to make sure the cancer has not spread.

Invasive cancer:

Surgery, radiation, chemotherapy or a combination of the three may be used for invasive cervical cancer.

Surgery:

Surgery is usually required if a biopsy shows that cancerous cells have invaded through a layer called the basement membrane, which separates the surface layers of the cervix from other underlying layers.
The cancerous cells may be removed or destroyed by using methods similar to those used to treat precancerous lesions, such as the LEEP or a cold knife conization if the cancer is only on the surface of the cervix. An operation may remove the tumor but leave the uterus and the ovaries if the disease has invaded deeper layers of the cervix but has not spread beyond the cervix.
A cone biopsy where removal of the inside of the cervix where most tumors begin and a trachelectomy where removal of the upper vagina and cervix are options that can be used for small tumors in order to preserve fertility.
If the disease has spread into the uterus, removal of the uterus and cervix called hysterectomy is usually necessary. Sometimes, the ovaries and fallopian tubes also are removed. In addition, lymph nodes near the uterus may be removed to check for spread of the cancer. Hysterectomy is also sometimes done to prevent spread of the cancer.
Pelvic exenteration is a procedure that is done in more advanced cancers which removes the uterus, surrounding lymph nodes, and parts of other organs surrounding the cancer, depending on its location.

Radiation Therapy:

Radiation therapy uses high powered energy beams, such as X-rays or protons, to kill cancer cells. Radiation therapy may be used alone or with chemotherapy before surgery to shrink a tumor. It can also be used after surgery to kill any remaining cancer cells.
Radiation therapy can be given:

• Externally, by directing a radiation beam at the affected area of the body which is known as external beam radiation therapy)
• Internally, by placing a device filled with radioactive material inside your vagina, usually for only a few minutes which is known as brachytherapy)
• Both externally and internally

Side effects of radiation therapy include fatigue, diarrhea, skin changes, nausea, vomiting, irritation of the bladder, vaginal irritation and discharge, and sometimes menstrual changes or early menopause, if the ovaries are exposed to radiation.
You should preserve your eggs before treatment starts if you might want to get pregnant after radiation treatment.

Chemotherapy:

Chemotherapy uses medications, usually injected into a vein, to kill cancer cells. Low doses of chemotherapy are often combined with radiation therapy. It may also be given before or after radiation treatment. The most common medication used for chemotherapy in cervical cancer are cisplatin and 5-fluorouracil. Chemotherapy may also be the treatment of choice for cervical cancer that has come back after treatment. Side effects of chemotherapy include nausea, fatigue, vomiting, hair loss, and mouth sores.

Targeted therapy:

It refers to drugs that have been specifically developed, or targeted, to interrupt cellular processes that promote growth of cancer cells. Bevacizumab or Avastin is an example of targeted therapy. It is a drug that inhibits the ability of tumors to make new blood vessels, which is required for tumor growth. This kind of targeted therapy is sometimes used for advanced cervical cancers.

Palliative care:

Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used along with aggressive treatments, such as surgery, chemotherapy and radiation therapy. People with cancer may feel better and live longer when palliative care is used along with other appropriate treatments . This can be used soon after diagnosing the disease.

Prevention of Cervical cancer:

Cervical cancer can often be prevented with vaccination and modern screening techniques that detect precancerous changes in the cervix. Pap screening can be done to detect precancerous changes, which can be treated before they progress to become cancer. Most medical organizations suggest women begin routine Pap tests at age 21 and repeat them every few years depending on their overall health condition.
Vaccines such as Gardasil and Gardasil 9 are available against the common types of HPV that cause cervical cancer.  Gardasil is very effective in preventing infection by four common HPV types that include 6, 11, 16, and 18 in young people who were not previously infected with HPV. Gardasil 9, a newer version of the vaccine, was approved in December 2014 and provides immunity to nine HPV types (6, 11, 16, 18, 31, 33, 45, 52, and 58).
Vaccination should occur before sexual activity to offer the full benefit of the vaccine. The recommended age to receive the HPV vaccine by CDC is 11 to 12 year for girls. Young women ages 13 through 26 should get the vaccine if they did not receive any or all doses when they were younger.
Gardasil is also approved for use in males aged 9 to 26. The recommended age to receive Gardasil by CDC is 11 or 12 years for all boys. It is also recommended for males aged 13 through 21 years who did not receive the full three vaccination series. Men can receive the vaccine up to age 26.
Using a condom, having fewer sexual partners and delaying intercourse may reduce your risk of cervical cancer. Quitting smoking can also help prevent cervical cancer to develop.