Battling cancer of the cervix

By Dr Hj Muhd Syafiq
Abdullah, Specialist
Oncologist

YOU have been told that you have cervix cancer. You ask yourself “So, what’s the next thing that I should do?” Do you want to know what is the best cervical cancer treatment?

Assessing the extent and spread

If you are found to have cervical cancer then further tests may be advised to assess if the cancer has spread. For example, a CT scan, blood tests or other tests such as Examination under Anaesthesia (EUA).
This assessment is called ‘staging’ of the cancer. The aim of staging is to find out:

- How much the tumour has grown, and whether it has grown to other nearby organs such as the bladder or rectum.
- Whether the cancer has spread to local lymph glands (nodes).
- Whether the cancer has spread to other areas of the body (metastasised).

Exactly what tests are needed depends on the initial assessment and the results of the biopsy. For example, the biopsy may show that the cancer is at a very early stage and remains just in the surface cells of the cervix. This is unlikely to have spread (metastasised) and you may not need many other tests. However, if the cancer appears to be more advanced and likely to have spread then a range of tests may be needed.
Finding out the stage of the cancer helps doctors to advise on the best treatment options. It also gives a reasonable indication of outlook (prognosis).

What are the treatment options for cervical cancer?

Treatment options which may be considered include surgery, radiotherapy, chemotherapy, or a combination of these treatments. The treatment advised for each case depends on various factors such as stages of the Cervical Cancer, patient’s desire to be pregnant again, patient’s age and fitness as well as types of treatments available

You should have a full discussion with specialists such as gynaecologist with interest in gynaecology cancer or oncologist (cancer specialist). You may be seen in a special clinic called Joint Cancer Clinic.

They will be able to give the pros and cons, likely success rate, possible side effects, and other details about the various possible treatment options for your type and stage of cancer. You should also discuss with the specialists the aims of treatment. Some cervical cancers can be cured, particularly if they are treated in the early stages of the disease. (Doctors tend to use the word ‘remission’ rather than the word ‘cured’. Remission means there is no evidence of cancer following treatment. If you are ‘in remission’, you may be cured.

However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)

In some cases, treatment aims to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.

In some cases, treatment aims to ease symptoms. For example, if a cancer is advanced then you may require treatments such as painkillers or other treatments to help keep you free of pain or other symptoms. Some treatments may be used to reduce the size of a cancer, which may ease symptoms such as pain.

Choices of cervical cancer treatment are based on cervical cancer stages when diagnosed. In early stage of cervical cancer, the cancer can be operated. But, when diagnosed at a late stage, it cannot be operated.

Surgery

An operation to remove the cervix and uterus (hysterectomy) is a common treatment. If the cancer is at an early stage and has not spread then surgery alone can be curative. In some cases where the cancer is at a very early stage, it may be possible to just remove the part of the cervix affected by the cancer without removing the entire uterus. This would mean that your fertility would not be affected.

If the cancer has spread to other parts of the body, surgery may still be advised, often in addition to other treatments. For example, in some cases where the cancer has spread to other nearby structures, extensive surgery may be an option. This may be to remove not only the cervix and uterus but also nearby structures, which may have become affected such as the bladder and/or rectum.

Even if the cancer is advanced and a cure is not possible, some surgical techniques may still have a place to ease symptoms. For example, to relieve a blockage of the bowel or urinary tract which has been caused by the spread of the cancer.

Radiotherapy

Radiotherapy is a treatment, which uses high energy beams of radiation which are focussed on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying. Radiotherapy alone can be curative for early stage cervical cancer and may be an alternative to surgery. For more advanced cancers, radiotherapy may be advised in addition to other treatments.

Two types of radiotherapy are used for cervical cancer, external and internal. In many cases both types are used.

External radiotherapy. This is where radiation is targeted on the cancer from a machine. (This is the common type of radiotherapy used for many types of cancer.)

Internal radiotherapy (brachytherapy). This treatment involves placing a small radioactive implant next to the cancerous tumour for a short time and then it is removed. (It is put in position via the vagina.)

Even if the cancer is advanced and a cure is not possible, radiotherapy may still have a place to ease symptoms. For example, radiotherapy may be used to shrink secondary tumours which have developed in other parts of the body and are causing pain.

Chemotherapy

Chemotherapy is a treatment using anti-cancer drugs which kill cancer cells, or stop them from multiplying.
Chemotherapy may be given in addition to radiotherapy or surgery in certain situations. Treatment according to stages

In stage 0, cancer can be treated with local destruction of malignant cells. There are two options. The cancer can be destroyed with ablative procedure, such as electro-coagulation diathermy, cryosurgery, or Laser CO2. It can also be treated with excision procedure like Cold-knife conization, Loop Electrosurgical Excision Procedure, or hysterectomy.

In stage Ia, cancer still can be operated with some options. If the patient doesn’t want to give birth anymore, she can choose total hysterectomy. If patient still wants to give birth, she should choose adequate cone biopsy.

In stage Ib – Ha, the options available include radical hysterectomy, radical pelvic radiotherapy, or radical vaginal trachelectomy. If patients are young and desire to have baby, she could choose radical vaginal trachelectomy.

In Localised Advanced Cervical Cancer or stage IIb – IVa, Treatment of choice is radiotherapy with chemotherapy but it have some contraindications such as bad health status, elderly, inadequate bone marrow, and inadequate renal functions.

In metastatic cervical cancer, treatments are aimed to reduce cervical cancer symptoms. Supportive treatments are recommended for metastatic cervical cancer.

Radiotherapy must be avoided for pregnant women. For cervical cancer found during preg
nancy, treatment may be delayed until after the baby is born.

It is important for patients to discuss the best cervical cancer treatment with her doctor.

What is the prognosis (outlook)?

The outlook is best in those who are diagnosed when the cancer is confined to the cervix and has not spread. Treatment in this situation gives a good chance of cure: For women who are diagnosed when the cancer has already spread, a cure is less likely but still possible. Even if a cure is not possible, treatment can often slow down the progression of the cancer.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of cancer is likely to respond to treatment.

Take home message

Cervix cancer is preventable and treatable. Get a Pap smear, stop smoking and adopt a healthy life style. Together we can beat Cervix cancer. – (Ministry of Health Public Awareness Programme)

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