Cervical and uterine cancer
CERVICAL AND UTERINE CANCER
CERVICAL AND UTERINE CANCER DEFINITION
The cervix is the lower, narrow end of the uterus (the organ where a fetus grows). The cervix leads from the uterus to the vagina (birth canal).
The main types of cervical cancer are squamous cell carcinoma and adenocarcinoma. Squamous cell carcinoma begins in the thin, flat cells that line the cervix. Adenocarcinoma begins in cervical cells that make mucus and other fluids.
Long-lasting infections with certain types of human papillomavirus (HPV) cause almost all cases of cervical cancer. Vaccines that protect against infection with these types of HPV can greatly reduce the risk of cervical cancer. Having a Pap test to check for abnormal cells in the cervix or a test to check for HPV can find cells that may become cervical cancer. These cells can be treated before cancer forms.
Cervical cancer can usually be cured if it is found and treated in the early stages.
CERVICAL AND UTERINE CANCER CAUSES
Cancer is the result of the uncontrolled division of abnormal cells. Most of the cells in our body have a set lifespan; when they die new cells are produced to replace them. Abnormal cells can have two problems:
- They do not die
- They continue dividing.
This results in an excessive accumulation of cells which eventually form a lump – a tumor. Scientists are not completely sure why cells become cancerous. However, there are some risk factors which are known to increase the risk of developing cervical cancer. These risk factors include:
HPV (HUMAN PAPILLOMA VIRUS)
Human papilloma virus infection is a sexually transmitted virus. There are over 100 different types of HPVs – 15 types can cause cervical cancer; probably 99% of them. In addition there are a number of types which can cause genital warts. It is estimated that HPV types 16 and 18 cause about 70% of cases cervical cancer while HPV types 6 and 11 cause 90% of genital warts.
Other HPV types can cause cervical intra-epithelial neoplasia (CIN) – the growth of abnormal cells on the surface of the cervix.
MANY SEXUAL PARTNERS, BECOMING SEXUALLY ACTIVE EARLY
Cervical cancer-causing HPV types are nearly always transmitted as a result of sexual contact with an infected individual. Women who have had many sexual partners generally have a higher risk of becoming infected with HPV, which raises their risk of developing cervical cancer. There is also a link between becoming sexually active at a young age and a higher risk of cervical cancer.
If a woman develops cervical cancer it does not mean she had several sexual partners, or became sexually active earlier than most other females. It is just a risk factor. Women who only ever had one sexual partner can develop cervical cancer.
Smoking increases the risk of developing many cancers, including cervical cancer.
WEAKENED IMMUNE SYSTEM
People with weakened immune systems, such as those with HIV/AIDS, or transplant recipients taking immunosuppressive medications have a higher risk of developing cervical cancer.
CERTAIN GENETIC FACTORS
Scientists at Albert Einstein College of Medicine of Yeshiva University found that women with certain gene variationsappear to be protected against cervical cancer.
LONG-TERM MENTAL STRESS
A woman who experiences high levels of stress over a sustained period may be undermining her ability to fight off HPV andbe at increased risk of developing cervical cancer it can cause, scientists at the Fox Chase Cancer Center reported.
GIVING BIRTH AT A VERY YOUNG AGE
Women who gave birth before the age of 17 are significantly more likely to develop cervical cancer compared to women who had their first baby when they were aged 25 or over.
Women who have had at least three children in separate pregnancies are more likely to develop cervical cancer compared to women who never had children.
Long-term use of some common contraceptive pills slightly raises a woman’s risk.
OTHER SEXUALLY TRANSMITTED DISEASES (STD)
Women who become infected with chlamydia, gonorrhea, or syphilis have a higher risk of developing cervical cancer. Scientists at the Medical University of South Carolina found that HPV infections last longer if Chlamydia also is present.
Studies in several countries have revealed that women in deprived areas have significantly higher rates of cervical cancer, compared to women who live in other areas. Studies have also found higher rates in women of working age in manual jobs, compared to women in non-manual jobs. The most likely reason is a difference in the proportion of women who have regular screening. Scientists at King’s College London found that some areas in South East England had rates that were three times higher than neighboring areas.
CERVICAL AND UTERINE CANCER PATHOPHYSIOLOGY
Human papillomavirus (HPV) infection must be present for cervical cancer to occur. HPV infection occurs in a high percentage of sexually active women. However, approximately 90% of HPV infections clear on their own within months to a few years and with no sequelae, although cytology reports in the 2 years following infection may show a low-grade squamous intraepithelial lesion.
On average, only 5% of HPV infections will result in the development of CIN grade 2 or 3 lesions (the recognized cervical cancer precursor) within 3 years of infection. Only 20% of CIN 3 lesions progress to invasive cervical cancer within 5 years, and only 40% of CIN 3 lesions progress to invasive cervical cancer with 30 years.
Because only a small proportion of HPV infections progress to cancer, other factors must be involved in the process of carcinogenesis. The following factors have been postulated to influence the development of CIN 3 lesions:
- The type and duration of viral infection, with high-risk HPV type and persistent infection predicting a higher risk for progression; low-risk HPV types do not cause cervical cancer
- Host conditions that compromise immunity (eg, poor nutritional status, immunocompromise, and HIV infection)
- Environmental factors (eg, smoking and vitamin deficiencies)
- Lack of access to routine cytology screening
In addition, various gynecologic factors significantly increase the risk of HPV infection. These include early age of first intercourse and higher number of sexual partners.
Although use of oral contraceptives for 5 years or longer has been associated with an increased risk of cervical cancer, the increased risk may reflect a higher risk for HPV infection among sexually active women. However, a possible direct interaction between oral contraceptives and HPV infection has not been disproved.
CERVICAL AND UTERINE CANCER SYMPTOMS
Often during the early stages people may experience no symptoms at all. That is why women should have regular cervical smear tests.
The most common symptoms are:
Bleeding between periods
Bleeding after sexual intercourse
Bleeding in post-menopausal women
Discomfort during sexual intercourse
Smelly vaginal discharge
Vaginal discharge tinged with blood
CERVICAL AND UTERINE CANCER DIAGNOSIS
Most women are not screened for endometrial cancer, so it’s most often diagnosed after a woman goes to her doctor because she has symptoms.
MEDICAL HISTORY AND PHYSICAL EXAM
If you have any of the symptoms of endometrial cancer (see “Signs and symptoms of endometrial cancer”), you should visit your doctor. The doctor will ask about your symptoms, risk factors, and medical history. The doctor will also perform a general physical exam and a pelvic exam.
SEEING A SPECIALIST
If there’s a possibility you could have endometrial cancer, you should be examined by a gynecologist, a doctor qualified to diagnose and treat diseases of the female reproductive system. Gynecologists can diagnose endometrial cancer, as well as treat some early cases. Specialists in treating cancers of the endometrium and other female reproductive organs are called gynecologic oncologists. These doctors treat both early and advanced cases of endometrial cancer.
Ultrasound is often one of the first tests used to look at the uterus, ovaries, and fallopian tubes in women with a possible gynecologic problem. Ultrasound tests use sound waves to take pictures of parts of the body. A small instrument called a transducer or probe gives off sound waves and picks up the echoes as they bounce off the organs. A computer translates the echoes into pictures.
For a pelvic ultrasound, the transducer is placed on the skin of the lower part of the abdomen. Often, to get good pictures of the uterus, ovaries, and fallopian tubes, the bladder needs be full. That is why women getting a pelvic ultrasound are told to drink lots of water before the exam.
A transvaginal ultrasound (TVUS) is often preferred for looking at the uterus. For this test, the TVUS probe (that works the same way as the ultrasound transducer) is put into the vagina. Images from the TVUS can be used to see if the uterus contains a mass (tumor), or if the endometrium is thicker than usual, which can be a sign of endometrial cancer. It may also help see if a cancer is growing into the muscle layer of the uterus (myometrium).
Salt water (saline) may be put through a small tube into the uterus before the ultrasound so the doctor can see the uterine lining more clearly. This procedure is called a saline infusion sonogram or hysterosonogram. (sonogram is another term for ultrasound.) Sonography may help doctors pinpoint the area they want to biopsy if other procedures didn’t detect a tumor.
SAMPLING ENDOMETRIAL TISSUE
To find out whether endometrial hyperplasia or endometrial cancer is present, the doctor must remove some tissue so that it can be looked at under a microscope. Endometrial tissue can be obtained by endometrial biopsy or by dilation and curettage (D&C) with or without a hysteroscopy. A specialist such as a gynecologist usually does these procedures, which are described below.
An endometrial biopsy is the most commonly performed test for endometrial cancer and is very accurate in postmenopausal women. It can be done in the doctor’s office. In this procedure a very thin flexible tube is inserted into the uterus through the cervix. Then, using suction, a small amount of endometrium is removed through the tube. The suctioning takes about a minute or less. The discomfort is similar to menstrual cramps and can be helped by taking a nonsteroidal anti-inflammatory drug such as ibuprofen before the procedure. Sometimes numbing medicine (local anesthetic) is injected into the cervix just before the procedure to help reduce the pain.
For this technique doctors insert a tiny telescope (about 1/6 inch in diameter) into the uterus through the cervix. To get a better view of the inside of the uterus, the uterus is filled with salt water (saline). This lets the doctor see and biopsy anything abnormal, such as a cancer or a polyp. This is usually done using a local anesthesia (numbing medicine) with the patient awake.
DILATION AND CURETTAGE (D&C)
If the endometrial biopsy sample doesn’t provide enough tissue, or if the biopsy suggests cancer but the results are uncertain, a D&C must be done. In this outpatient procedure, the opening of the cervix is enlarged (dilated) and a special instrument is used to scrape tissue from inside the uterus. This may be done with or without a hysteroscopy.
This procedure takes about an hour and may require general anesthesia (where you are asleep) or conscious sedation (given medicine into a vein to make you drowsy) either with local anesthesia injected into the cervix or a spinal (or epidural). A D&C is usually done in an outpatient surgery area of a clinic or hospital. Most women have little discomfort after this procedure.
TESTING ENDOMETRIAL TISSUE
Endometrial tissue samples removed by biopsy or D&C are looked at under the microscope to see whether cancer is present. If cancer is found, the lab report will state what type of endometrial cancer it is (like endometrioid or clear cell) and what grade it is.
Endometrial cancer is graded on a scale of 1 to 3 based on how much it looks like normal endometrium. (This was detailed in “What is endometrial cancer?”) Women with lower grade cancers are less likely to have advanced disease or recurrences.
If the doctor suspects hereditary non-polyposis colon cancer (HNPCC) as an underlying cause of the endometrial cancer, the tumor tissue can be tested for protein changes (such as having fewer mismatch repair proteins) or DNA changes (called microsatellite instability, or MSI) that can happen when one of the genes that causes HNPCC is faulty. If these protein or DNA changes are present, the doctor may recommend that you see a genetic counselor to consider genetic testing for the genes that cause HNPCC. Testing for low mismatch repair protein levels or for MSI is most often ordered in women diagnosed with endometrial cancer at a younger than usual age or who have a family history of endometrial or colon cancer.
TESTS TO LOOK FOR CANCER SPREAD
If the doctor suspects that your cancer is advanced, you will probably have to have other tests to look for cancer spread.
COMPUTED TOMOGRAPHY (CT)
The CT scan is an x-ray procedure that creates detailed, cross-sectional images of your body. For a CT scan, you lie on a table while an X-ray takes pictures. Instead of taking one picture, like a standard x-ray, a CT scanner takes many pictures as the camera rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of many slices of the part of your body that is being studied.
Before any pictures are taken, you may be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You may also receive an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body.
The injection can cause some flushing (redness and warm feeling that may last hours to days). A few people are allergic to the dye and get hives. Rarely, more serious reactions like trouble breathing and low blood pressure can occur. Medicine can be given to prevent and treat allergic reactions. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays.
CT scans are not used to diagnose endometrial cancer. However, they may be helpful to see whether the cancer has spread to other organs and to see if the cancer has come back after treatment.
CT scans can also be used to precisely guide a biopsy needle into a suspected area of cancer spread. For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table while a doctor moves a biopsy needle toward the mass. CT scans are repeated until the doctor is sure that the needle is inside the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½ inch long and less than 1/8 inch in diameter) is removed and looked at under a microscope.
CT scans take longer than regular x-rays. You might feel a bit confined by the ring you lie within when the pictures are being taken.
MAGNETIC RESONANCE IMAGING (MRI)
MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. This creates cross sectional slices of the body like a CT scanner and it also produces slices that are parallel with the length of your body.
MRI scans are particularly helpful in looking at the brain and spinal cord. Some doctors also think MRI is a good way to tell whether, and how far, the endometrial cancer has grown into the body of the uterus. MRI scans may also help find enlarged lymph nodes with a special technique that uses very tiny particles of iron oxide. These are given into a vein and settle into lymph nodes where they can be spotted by MRI.
Sometimes a contrast material is injected into a vein, just as with CT scans. The contrast used for MRI is different than the one used for CT, so being allergic to one doesn’t mean you are allergic to the other. MRI scans are a little more uncomfortable than CT scans. First, they take longer, often up to an hour. Also, you have to be placed inside a tube, which is confining and can upset people with fear of enclosed places. Special, “open” MRI machines can help with this if needed, however the drawback is that the images may not be as good. The machine also makes a thumping or buzzing noise that you may find disturbing. Many places will provide headphones with music to help block out this noise.
POSITRON EMISSION TOMOGRAPHY (PET)
In this test radioactive glucose (sugar) is given to look for cancer cells. Because cancers use glucose (sugar) at a higher rate than normal tissues, the radioactivity will tend to concentrate in the cancer. A scanner can spot the radioactive deposits. This test can be helpful for spotting small collections of cancer cells. Special scanners combine a PET scan with a CT to more precisely locate areas of cancer spread. PET scans are not a routine part of the work-up of early endometrial cancer, but may be used for more advanced cases.
CYSTOSCOPY AND PROCTOSCOPY
If a woman has problems that suggest the cancer has spread to the bladder or rectum, the inside of these organs will probably be looked at through a lighted tube. In cystoscopy the tube is placed into the bladder through the urethra. Inproctoscopy the tube is placed in the rectum. These exams allow the doctor to look for possible cancers. Small tissue samples can also be removed during these procedures for pathologic (microscopic) testing. They can be done using a local anesthetic but some patients may require general anesthesia. Your doctor will let you know what to expect before and after the procedure. These procedures were used more often in the past, but now are rarely part of the work up for endometrial cancer.
COMPLETE BLOOD COUNT
The complete blood count (CBC) is a test that measures the different cells in the blood, such as the red blood cells, the white blood cells, and the platelets. Endometrial cancer can cause bleeding, which can lead to low red blood cell counts (anemia).
CA 125 BLOOD TEST
CA 125 is a substance released into the bloodstream by many, but not all, endometrial and ovarian cancers. If a woman has endometrial cancer, a very high blood CA 125 level suggests that the cancer has probably spread beyond the uterus. Some doctors check CA 125 levels before surgery or other treatment. If they are elevated, they can be checked again to find out how well the treatment is working (for example, levels will drop after surgery if all the cancer is removed).
CA 125 levels are not needed to diagnose endometrial cancer, and so this test isn’t ordered on all patients.
CERVICAL AND UTERINE CANCER TREATMENT
The prognosis (chance of recovery) and treatment options depend on the following:
The stage of the cancer (whether it is in the endometrium only, involves the whole uterus, or has spread to other places in the body).
- How the cancer cells look under a microscope.
- Whether the cancer cells are affected by progesterone.
Endometrial cancer is highly curable.