GLOBOCAN statistics 2020 shows that cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women, with an estimated 604,000 new cases and 342,000 deaths worldwide in 2020. Seventy per cent of cervical cancers occur in low-resourced countries.
Malaysia National Cancer Registry of 2012-2016 reported cervical cancer as the third most common cancer among women after breast cancer and colorectal cancer. The incidence rate has decreased from 7.6 to 6.2 per 1000,000 population over the five years. Dr Santhi Nadarajan, consultant clinical oncologist from Gleneagles Hospital Kuala Lumpur answers some common questions surrounding cervical cancer.
There are several aetiological factors for cervical carcinoma. The most significant one is due to persistent infection of the sexually transmitted human papillomavirus (HPV) strains, particularly type 16 and 18 as they are the most common (70% of cases). The HPC infection usually occurs at the basal epithelium and will resolve spontaneously. However, if the infection persists, it may progress into a high-grade cervical intraepithelial neoplasia (CIN). This is a cancer precursor.
Other risk factors include tobacco smoking, multiple pregnancies, multiple sexual partners, prolonged use of oral contraceptives and lower socioeconomic status.
Screening for cervical carcinoma using the Papanicolaou Smear test (Pap) was identified as an effective screening tool for early detection of precancerous state. This test has been available in Malaysia since 1960 and the participation rate has increased since the healthy lifestyle campaigns against cancer in 1995. Both public and private sectors have contributed to strengthening this programme. The Current recommendation is for all women who are or have been sexually active between the ages of 30-65 years old or sexually active but less than 30 years old to perform screening tests that include Pap smear and HPV testing. If one or two consecutive results turn out negative, the women can proceed with Pap smear screening every three years. If the result is abnormal, you may need to go for a colposcopy.
Individuals in the early stages of the disease may have no symptoms. Others can present with vaginal bleeding between menstrual cycles, bleeding after sexual intercourse, vaginal bleeding in post-menopausal women, vaginal discharge with a strong odour or tinged with blood and pelvic pain.
Pathological diagnosis should be made through a biopsy from the suspicious cervical lesion. A complete pelvic examination with/without anaesthesia is mandatory to gather the information required for the staging. The two commonly used staging for cervical cancer is the International Federation of Gynaecology and obstetrics (FIGO) staging and the American Joint Committee on Cancer (AJCC) and the International Union against Cancer (UICC) Tumour node Metastasis (TNM) staging system.
In our practice in Malaysia, cervical carcinoma is staged clinically based on the FIGO staging system. This system is based on clinical findings and not surgical results. The assessment includes specific clinical examinations and diagnostic tests. It consists of palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, radiography (radiography of lungs and skeleton) and cervical colonisation. Apart from that, blood parameters such as full blood count, renal and liver profile, and high-risk screening for those with risk factors are permitted. Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI) are allowed if available to complement Examination under Anesthesia (EUA) for surgical decision-making. However, this radiological imaging is not included in FIGO.
The primary treatment for cervical cancer consists of surgery, radiation, and chemotherapy, given either as a single modality or a multimodal approach. However, the selection of the appropriate treatment is based on many factors namely, disease stage, histological parameters such as lymph node status, tumour size, adequacy of surgical margin, and patient preference and performance status. They are many international guidelines available for reference to assist the treatment selection. The European Society for Medical Oncology (ESMO) and the National Comprehensive Cancer Network (NCCN) have released their guideline based on the stage of the disease. The recommendations are widely adopted in many parts of the world. These recommendations are also in practice in our local context in Malaysia.
Generally, early stages (stage I-IIA) are treated with radical hysterectomy and pelvic lymphadenectomy or radiotherapy and pelvic lymphadenectomy or radiotherapy. Colonisation is an alternative to hysterectomy in young patients with stage IAI disease who wish to maintain fertility, provided the depth of invasion is less than 3mm (≤1% risk of lymph nodes metastasis), no lymphovascular invasion and margin not involved by tumour.
Early-stage disease with FIGO IA2 and IIA can also be managed with either surgery or radical radiotherapy with similar outcomes. Apart from that, Stage IA-IIA with high-risk features (positive pelvic lymph nodes, involved surgical margins, and/or parametrial); adjuvant concurrent chemoradiotherapy (CCRT) with cisplatin-based chemotherapy is recommended and those women with locally advanced disease (stage IIB, III or IVA); definite CCRT (with cisplatin-based chemotherapy) and brachytherapy is recommended. Patients with metastatic disease (IVB) or recurrence; are treated with radiation for local control, pain or bleeding and systemic chemotherapy for disseminated disease.
The decision regarding optimal treatment for localised cervical cancer is very complex. Survival outcome and local control are the main objectives. Treatment is also aimed at reducing morbidity and related toxicities.
Written by
Consultant Clinical Oncologist
Gleneagles Hospital Kuala Lumpur
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