Cervical Cancer And The African Woman BY ELIJAH UGANI

In Breaking News, Columnists, Health, Opinion

Introduction

Cervical cancer is a type of cancer that begins in the uterine cervix, the lower end of the uterus that contacts the upper Vagina.

Cervical cancer occurs in almost 13,000 women each year in the United States, leading to about 4,100 deaths.

Since 1980, the incidence of cervical cancer has declined by 49 percent. Survival rates among African women are lower than for any other racial or ethnic group in the United States.

Cervical cancer is the cancer of the cervix and it is a potentially preventable disease. It is the second most common malignancy in women in developing countries. In Northern part of Nigeria, it is the commonest cancer in women while in Southern Nigeria, it is second to breast cancer.

In developed countries, the incidence of the disease has decreased over the years because of the availability of well-organised cervical cancer screening programs, which allows the detection of the curable prelignant disease.

Cervical cancer affects the neck of the womb or cervix. The cervix connects the uterus and Vagina incidence. It is the second most common cancer among women worldwide. Over 500,000 women worldwide die of cervical cancer annually.

About 47.7 million Nigerian females, aged 15 years and above, are at risk of cervical cancer (according to Okeye, 2015). Cervical cancer remains a common cause of cancer and cancer deaths in women in developing countries without access to screening (pap testing) for cervical cancer or vaccine against HPV.

Cervical cancer is different from cancer that begins in the otherregio of the uterus (uterine or endometrial cancer). If detected early, it has a very high cure rate. Vaccination against HPVs, which is known to cause cervical cancer, is an effective prevention measure.

Causes Of Cervical Cancer

Almost all cervical cancer are caused by longstanding infection with one being HPVs. HPV infection is very common, and most people with HPV infection do not develop cancer. There over 100 types of HPVs, and only certain types have been linked to cancer. Other HPV types cause benign warts on the skin or genitals.

The so-called HPV types have been shown to cause cancers of the cervix as well as as cancers of the pelvis in men. HPV can also cause cancers of the mouth, throat, and anus in people of both sexes.

HPV infection is spread through sexual contact or skin-to-skin contact. Many studies have shown that HPV infection is common and that majority of the people will be infected with HPV at some point in life. The infection typically resolves on its own. In some women, the HPV infection persists and causes precancerous changes in the cell of the cervix.

These changes can be detected by regular cervical cancer screening (pap testing). With pap testing, a superficial sample of cells from the cervix is taken with a brush or swab during a routine pelvic examination and sent to a laboratory for analysis of cell appearance.

Dysplasia is abnormal appearing cells that are not cancers but may be precancerous. Dysplasia of the cervix identified at the time of pap testing is referred to as a Squamous Intraepithelial Lesion (SIL). Cervical Intraepithelial Neoplasia (CIN) is another term used to classify precancerous changes in the cervix that are seen or tissue samples such as biopsies. Precancerous changes in the cervix such as CIN and SIL can typically be treated, which can prevent the development of cancer.

The cervix itself contains two types of cells – the living cells of the outer cervix, known as squamous cells, and the cells that live in the interior channel of the cervix. These interior cells have features of glandular cells.

The point at which the squamous and the glandular cells meet is called the transition zone, and it is in this area that most cervical precancerous and cancer begin to grow. Up to 90 percent of cervical cancers arise from the squamous cells and are called squamous cells carcinomas, with most of the remainder coming from the glandular cells (adenocarnomas).

Symptoms

Cervical cancer may not produce any symptoms or signs in particular. Easily stage cervical cancer, like precancerous changes, typically do not produce symptoms. Symptoms may develop when the cervical cancer cells start to invade the surrounding tissue.

Some of the signs are: Abnormal vagina bleeding, vagina bleeding after menopause, vagina bleeding after sex, bleeding in between periods than usual, other abnormal vagina discharge, pain during sexual intercourse.

It is important to note that these symptoms are not specific to cervical cancer and can be caused by a variety of conditions.

Risk Factors

Cervical cancer can cause infection with one of the high risk HPV types. However, since not all people who are infected with HPV will develop cancer, it is likely that other factors also play a role in the development of cervical cancer.

Certain risk factors have been identified that increase a woman’s risk for developing cervical cancer: Tobacco smoking, HIV infection, Immune system suppression, over weight, long-term use of oral contraception (the risk returns to normal when the contraceptive oils are discontinued), having three or more full-time pregnancies, having a first time pregnancy before 17 years, poverty and family history of cervical cancer.

Screening

The United States Preventive Services Task Force (USPSTF) and America Cancer Society (ACS) recommend that all women between the ages of 21 to 65 receive screening every three years. A pap smear obtained during routine pelvic examination is the typical screening procedure, but when a pap smear is combined with HPV test, screening every five years is acceptable for women aged 30 and above.

Women who have had a total hysterectomy for a benign condition no longer have a cervix, and thus do not need to be screened for cervical cancer. However, women who have had a sub total hysterectomy still have a cervix and should be screened according to guidelines.

Diagnosis

As described above, pap testing is done to screen for cervical cancer. If abnormal cells are detected on the pap smear, a colposcopy procedure is then performed. Colposcopy uses lighted microscope to examine the external surface of the cervix during a pelvic examination. If the abnormal areas are noted, a small tissue sample (biopsy) is taken for examination by a pathologist to look for precancerous changes or cancers. Colposcopy requires no special anesthesia and is similar to having a pap smear in terms of discomfort.

The transformation zone of the cervix cannot always be visualised well during colposcopy. In this case, a sample of cells may be taken from the ulterior canal of the cervix, known as an endocervical curettage or scrapping.

Another option is conization, or removal of a cone-shaped portion of the cervix around the cervical canal. This tissue can be removed with a tin loop of wire that is heated by an electrical current known as Loop Electro surgical Excision Procedure (LEEP), also called a Large Loop Excision of the Transformation Zone (LLETZ). LEEP is performed in the doctor’s office with a local anesthetic. Another possibility to have the cone-shape tissue fragment removal in an operating room under general anesthesia, referred to as a cold knife conization.

After a conization or biopsy procedure, the pathologist studies the tissue to determine if precancerous changes (referred to as cervical Intraepithelial neoplasia grades 1 to 3, depending on its extent) or cancer are present. If cancer is present depending on size and extent of the tumor, other tests might be done to help determine the extent to which the tumor has spread.

These additional tests can include: Chest X-rays, or CT, or MRI imaging studies. Cystopscopy (examination of the interior of the urinary bladder using a thin, lighted scope) or protoscopy (examination of the rectum) may be necessary. An examination under anesthesia allows the doctor to perform a manual pelvic examination without causing pain to help determine the degree of spread of the cancer within the pelvis.

Stages Of Cervical Cancer

The stage of any cancer refers to the extent to which it has spread in the body at the time of diagnosis. Staging cancer is an important part of determining the best treatment plan. Both the International Federation of Gynecology and Obstetrics (FIGO) system and American Joint Committee on Cancer (AJCC) have developed systems to stage cervical cancer.

Both systems are based on the tumor extent, spread to any lymph nodes and distance spread. Cervical cancer is classified in stages from 0 to iv, with many sub categories within each numerical stage.

In general, the stages of cervical cancer are as follows:

Stage 0: This stage is not a true invasive cancer. The abnormal cells are only on the surface of the cervix, as in CIN 3. This stage is not included in the FIGO system and referred to as carcinoma.

Stage i: This small amount of tumor present 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: This is the most advanced stage, in which the cancer has been spread to the bladder or rectum, or to sites in other areas of the body.

Treatment

The treatment for cervical cancer depends upon many factors, including the stage of the cancer when it is diagnosed. Surgery, radiation therapy, chemotherapy, and targeted therapy are common methods of treatment for cervical cancer. Different kinds of doctors may be involved in the treatment including: Gynecology oncologist, a physician who specialises 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 cancers. Medical oncologist, a specialist in the use of chemotherapy and other medical therapies to treat cancer.

Methods of treatment

Surgery is often performed to removed the cancer, especially in early stage tumors. Hysterectomy (removal of the uterus). This may be performed, but other procedures that preserve the ability to carry a pregnancy can be done in younger women with small tumors. Both a cone biopsy (removal of the inside of the cervix where most tumors begin) and a trechelectomy (removal of the upper Vagina and cervix) are options that can be used for small tumors in order to preserve fertility. With more advanced cancers, a procedure known as pelvic exenteration removes the uterus, surrounding lymph nodes, and parts of the other organs surrounding the cancer, depending on its location.

Radiation therapy is another common treatment for cervical cancer. External beam radiation therapy (radiation therapy administered from an outside source of radioactive sources near the tumor for a fixed period of time) have been used for cervical cancer.

These two types of therapy have also been used together. If radiation therapy used is given as the main treatment for cancer, it is often combined with chemotherapy. Side effects of radiation therapy include: Fatigue, diarrhea, skin changes, nausea, vomiting, irritation of the bladder, Vagina irritation and discharge, and sometimes menstrual changes or early menopause. If the ovaries are exposed to radiation.

Chemotherapy may be recommended together with radiation therapy (chemoradiation) for some stages of cervical cancer. It may also be given before or after radiation treatment. Chemotherapy drugs commonly used for cervical cancer include 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 refers to drugs that have been specifically developed, or targeted, to interrupt cellular processes that promote growth of cancer cells. Bevacizumab (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 cancer.

Cervical Cancer Vaccine

Cervical cancer can often be prevented with vaccination and modern screening techniques that detect precancerous changes in the cervix. The incidence of cervical cancers in the developed world decline significantly after the introduction of pap screening to detect precancerous changes in the cervix which can be treated before the progress to become cancer.

Moreover, vaccines are available against the common types of HPV that cause cervical cancer. Vaccination should occur before sexual activities to offer full benefit of the vaccine. The CDC recommends that 11 to 13 year old girls receive the HPV vaccine, and 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 age 21 years who did not receive the full three vaccination series. Man can receive the vaccine up to age 26.

Support Available For Cervical Cancer

As with any cancer diagnosis, emotional support from family, friends, clergy, a counselor or support group can help one learn about the illness and how to cope with the diagnosis and effects of treatment. Every woman is different, and different women will be comfortable with different kinds of supports systems.
For those who prefer a more organised form of support, patients and family support groups are offered by cancer treatment centers, hospitals and clinics, national advocacy organisations, local places of worship may also provide cancer support groups.

There are even online support groups for those who prefer this option, the following provides a partial listing of sources for emotional and coping support for those with cervical cancer: The American Cancer Society (ACS) Cancer Survival Network; I can cope (online) is an ACS sponsored online course in coping with cancer; the National Cancer Information Center which provides information and support to those 24 hours a day, 365 days a year as well as the National Cervical Coalition which offers online support groups and coping resources and guide on sexuality for women.

Prognosis Of Cervical Cancer

As with most cancers, the outlook (prognosis) is better for cancers that are detected in the early stages than for advanced cancers. Prognosis for cancers is often reported in five years survival rates. Currently, survival rates for cervical cancer are based on patients who were diagnosed years ago, so these rates may be different in people today and receiving modern treatments. It is also important to note that many people with cancer live far beyond five years, and these rates include death from any cause, not just the cancer.

The five year survival rates by stage for cervical cancer are as follows:

Stage i: 80% – 93%
Stage ii: 53% – 63%
Stage iii: 32% – 35%
Stage iv: 15% – 16%

Survival rates are based on examination of large groups of people and do not reflect the outcome or expected course for any one individual patient. Many other factors including overall health status and the response of a cancer patient to treatment, can affect the prognosis of a specific patient.

Research On Cancer

Research on Cancer is ongoing, not only to improve methods to treat cervical cancer, but also methods to improve methods of treating precancers and detecting cancers in early, treatable stages.

Treatments, including the application of antiviral medications to the cervix, are being studied as alternative or complement to surgical management of precancerous changes in the cervix. For existing cancers, new targeted therapies are always been studied. Testing of HPV vaccines may be able to help a woman’s immune system fight off an existing HPV infection. Clinical trials (research studies that involve actual patient looking at new treatments or combination of treatment for a condition) are options for many cancer patients.

Elijah Ugani is CrossRiverWatch’s health correspondent

NOTE:Opinions expressed in this article are strictly attributable to the author, Elijah Ugani, and do not represent the opinion of CrossRiverWatch or any other organization the author works for/with.

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