What is Cervical Cancer?
The cervix is the lowest most narrow part of the uterus that connects the uterine cavity to the vagina. Apart from forming a passage way to the uterine cavity, it plays an important physiological role in reproductive and sexual function, pregnancy, birth.
Cancer of the cervix arises from either the surface layer of cells on the external part of the cervix that opens to the vagina (squamous cells), or the glandular cells of the canal of the cervix that leads into the cavity of the uterus.
What is the cause of Cervix Cancer?
Human papilloma virus (HPV) is the cause of almost all cases of cervical cancer. There are comparatively rare cases of cervical cancer not caused by HPV.
Is there a test for Cervix Cancer?
In Australia we are very fortunate to have a long established and successful screening program for cervical cancer. The screening program can detect individuals with pre-cancerous changes to undergo treatment to prevent progression to cervical cancer. We also have one of the world’s highest coverage of vaccination against high risk HPV.
Currently the national cervical screening program recommends a primary HPV test called a “cervical screening test” to asymptomatic women aged 25 and over. If negative it should be repeated every 5 years. If a high risk subtype of HPV is detected, then the cells collected (with a clinician collected test) are examined (cytology). If the specimen was a self collect specimen, women are directed to undergo a clinician collected test for cytology. Cytology can predict pre-cancerous and cancerous cell changes.
According to a risk algorithm, women are either directed to undergo colposcopy (an examination of the cervix with a microscope, to detect visual abnormalities and direct a tissue biopsy), or for a repeat cervical screening test in 12 months.
Pre-cancerous changes (high grade squamous intra-epithelial lesion, HSIL, cervical intra-epithelial neoplasia, CIN, adenocarcinoma in situ, AIS, ACIS) are diagnosed on tissue punch biopsy at colposcopy. These precancerous changes are treated with a procedure to excise the abnormality and the area on the cervix most likely affected by HPV (‘transformation zone’). This is either done with an electrocautery loop wire (termed LLETZ – ‘large loop excision of transformation zone’, or LEEP – ‘loop electrosurgical excision procedure’), or a cone biopsy performed with a scalpel.
Cervical cancer is also diagnosed by tissue biopsy – either a punch biopsy or LLETZ/cone biopsy.
Frequently Asked Questions
The optimal treatment of cervix cancer depends on the exact type and stage of cancer. In general terms smaller cancers confined to the cervix are usually treated with surgery. Larger cancers and cancers that have spread beyond the cervix to the pelvic area are treated with a combination of radiotherapy and chemotherapy. For women where cervical cancer has spread beyond the pelvis, treatment is individualised but typically will involve chemotherapy and immunotherapy, and in some cases radiotherapy. Preservation of the uterus for fertility is possible in carefully selected cases of very early stage cancers caused by HPV.
To assign a stage of cervical cancer, we use information from physical examination and tissue biopsy or surgical pathology results and also an MRI scan and PET-CT scan may be used.
For women who are suitable for surgery, the extent of surgery required depends on the exact type and stage of cervical cancer. This may range from a cone biopsy, to a radical hysterectomy and removal of pelvic lymph nodes. Radical hysterectomy means removing additional tissue around the cervix (parametrium of ligaments of the cervix and upper vagina) to obtain a clear margin around the cervical tumour.
It is often safe to keep the ovaries in place (and therefore not enter menopause if premenopausal) but this is an individualised recommendation based on the cancer type and size, and a woman’s menopausal status and wishes.
Larger cervical tumours, or with spread outside the cervix to the pelvic region are best treated with chemoradiation and brachytherapy. These treatments are prescribed by a radiation oncologist, and medical oncologist and consist of a 5 week course of external beam radiation with a dose of chemotherapy at the start of each week, followed by several doses of internal radiation (brachytherapy) using equipment that hugs the cervix and delivers radiation directly to the tumour.
Typically after treatment you will be followed closely for 5 years. At your follow up visits after a clinical review, a physical examination is performed. Typically scans or imaging studies are triggered by new symptoms or findings on examination.
All types of cancer have an associated risk of recurrence following successful treatment. You will be monitored closely following treatment in a schedule tailored to your risk category. If your cancer recurs, treatment options will depend on where the cancer has recurred, what treatment you initially received.
Preservation of the uterus for fertility is possible in carefully selected cases of very early stage cancers caused by HPV.
Yes. Cervical cancer is a preventable cancer. HPV vaccination can prevent over 90% of cases of cervical cancer.
If you have a positive HPV test, avoid smoking, vaping or exposure to cigarette smoke. This is a strong modifiable risk factor for development of pre-cancer and cancer when HPV is present.
Maintain involvement in the cervical screening program, talk about it with friends and family and encourage them to do the same.
If you have symptoms of abnormal vaginal bleeding or discharge (including spotting between periods, bleeding with intercourse, heavy and/or pronged menstrual periods, bleeding after menopause) or persistent pelvic pain or discomfort, see your GP for a pelvic examination and cervical co-test (HPV test and cytology for women with abnormal symptoms).
Ensure you and your children (female and male) are vaccinated against high risk HPV. The HPV vaccination (Gardasil(R)9 – covering 9 high risk HPV subtypes) is available as a paid vaccination for females and males aged 25 and over and will still provide benefit especially if you are sexually active and have not been exposed to all of the 9 subtypes covered by the vaccine. If you are under 25 and missed the vaccination in school you can still receive it for free under the catch up program. Consult with your GP regarding this.
If you are facing a new diagnosis of cervical cancer or suspected cervical cancer, write down any questions you can think of, bring a family member or friend to your specialist appointment, and reach out to those around you and the resources below for support.